P - 76108REQUEST FOR ELECTRICAL INSPECTION
1� 7 8 7� 0 8 9 � Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
.DesGribe -using the back of tha white copy'rf ne��na ����ny�i��r S S�I 2 TCH
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`' �GENERAL FEES Outdoor Liahtina Standard (�a. $1
GRCUITS OF LESS THAN 50 VOLTS
5ystem Device or Apparatus @ $.50
�' ADDITIONS TO THE GENERAL FEES
Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
� Transformer / Power Supply for Signs / Outline LlghUng @$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Taro Inspectlon Trips Each Dwelling Unit @$80
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1Y BE ORDERED DISCONNECTED IF NOT
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1787089�
total fee is
electrical installatlon describ2d herein on the dates ste0ed:
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�� Rough-in Inspection Required? ❑Yes� i�] No Inspection Other Than Rough-In: [�Ready Now �Will Call
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You must call the inspector when ready! Date Ready:
I cBrt�y that I am the C�J LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
JobSiteStreetAddress ��vFFiIDLEY �Ihl 55q�3`—
133 hIE GHRTSTEhISC�h! Ci' S
=W EUGE�IE �i
Electrical UBlity
hlEEG f
npany Name
LEGTFiIC CORF'Of;�1T'TOht
�Fi�iIT(�F:T�iL �FtO�DPerfSAl�hIT��F
�ature (ConVactor or Owner Perfortning Installation)
49�8
Fire No. County
Ah�OKA
Please Pravide Two (2) Phone Numbers
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:ontractor Ucense Number Master Electrician or Pawer
CA (jQ$$,j License Number
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