P - 75455REQUEST FOR ELECTRICAL INSPECTION
1��� o� 4 2 2� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
D�scribe -uging the back of the whRe copy if n work cbvered by this request ,
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6�%\�I6 1� "tAP� � 1A 1 1 �W � '� ♦
�" GENERAL FEES oor Li g Standard @$1
SERVICES / POW R SUPPLIES Traffic Slqnal Standard (a� $5
URS, CIRCUITS OF LESS THAN 50 VOLTS
Each St�stem Devi� or Aaaa�atus C�D $.50
CeMer Pivot Irriaation Boom
Inciudes the Servtce andlor Power Supply up to 500 Amperes, A�
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins 'on Tri $20
Imesdgative Fee
Reins 'on F� $20
TOTALFEE �/�e
(minimum total fee is $20) �- `�d
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I hereby ce�tlfy that I irrepected the elecMcal Inatellatlon descri�ed here6i on fhe dat� steted:
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� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI�1 �
FC}R OFFIGE USE' ONiY
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�� � Rough-fn Inspectlon Requfred? Yes ❑ No Inspectian Other Than Rough-In: � Ready Now ❑1Nm Call
���� You must ceU the inspector when ready! Date Ready.
I cerMy that I am the � LICENSED CONTRACTOR ❑ COMPANY'�OWNER and hereby request inspection of the electrical work at
Job Site Str�t Address _ 1 v c .�r �� �' � I
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ador License Number Master ElecMctan or Power Limited
License Number
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PI Provide Txw (2) Phcrte Nwnbers Including Ar�
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