P - 76156REQUEST FOR ELECTRICAL INSPECTION
�����- 4 4 4� Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
)escribe -using the bac� the wh' py'rf n� ry- th work ered„�s est: � o (1���
J w'r� %!/I CJ
�_ G ERAL FEES Out oor Liq ' q Standard an. $1
0 to 400
aver 10 KVA
w nm re� ONE & TWO FAMILY DWEWNGS, EACH UNIT
200 Am re$10 Includes the Service andlor Power Supply up to 500 Ampere,s, M
1MMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Un(t @$BO
CIRCUITS OF LESS THAN 50 VOLTS Addi�onal Ins on Tri $20
iystem Device or Ap tus Q$.50 Irnestigative Fee
ADDITIONS TO THE GENERAL FEES Re 'on Fe� $20
ILY DWELLINGS ER UN TOTAL FEE
� units @$50 Per Unit (minimum total fee is $20)
Idd'Nonel UNt @ $25 nasa�nr�wsa�croausEmar
OTHER ADDITIONAL FEES ���{/-'
Retrofit (a3 $25 per Focture I nereby certlfy mac I 6mpedea fhe electrlcal hismpana, desamed hereTn �the dams stated:
Piwt IrtiaaGon Boom a(� �40 �+a onre
ion a $30��erHour ���"—
ion @ $.37 per M'ile
ATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED VYITf
FOR GFF';�= i "SE OtiLr
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/�'J Rough-in Inspectlon RequiredT ❑ Yes ❑ No Inspectlan Other Rough-In: (�,Ready Now � Wip Ca➢
(/6 3� � You must call the inspedor when readyl Date Ready. /������
I cer6fy that I am the ❑ UCENSED CONTRACTOR ❑ COMPANY � OWNER and hereby request inspaction af the elechical ovork at
Job Sit� Street Addrer� /g � 1 ..�s �KY r e
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Please Provide Two (2) Pho�re N u
Vfi����G �� G V/I��6
Address
CoMractor License Nurttber Master Elecbictian or Power L
Licer�se Number
3on)
Please Provide Two (2) Ptrone Numbers Includli
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