P - 75869REQUEST FOR ELECTRICAL INSPECTION '
I �� � � � � 7 � /j Minnesota Board of Electricity �/)�� Q ��g$
�= " L{� 1821 University Avenue Suite S-128, n lsaul, mnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
Descdbe -using the back of the wh cwpy'rf necessary - the work covered by this requast: s�
Se�-1 �05�'�% /�%��S
GENERAL ES Outdoor Lighfin Standard @$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard @$5
0 to 400 Am�re na $25 Suontemental F� (�D SZ(1
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCURS, CIRCUITS OF LESS THAN 50 VOLTS
Each Addfional Unit @ $25
OTHER ADDRIONAL
Uahtinn Ratrofit (rD. $.25 oer Fodure
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit (a� $80
Additional Ins 'on T $20
Inve.stigative Fee
Reins 'on F� $ZO
TOTAL FEE ,r� ��
(minimum total f� is $20) p�v
THIS NF�A FOR N6PECfOR USE OtLLY
I herebv certify that I inspected tlre electrical Lislallatlon desczibed herein on fhe dat� stated:
� rate Bondin � Ins � on� $20v �J— : �
scial Ins 'on @ $30 per Hour °�°'"�'"m0� °A�
zaal Ins 'on @ $.31 �r Mile
IIdSTALLATIOPI MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
r-or� o�=ECe use or�� r
Ill�ll{IIII�IIII�IIII��I�IIIIIIa1�0�1� ��Hw���� �
18879734
��� / Rough-in Inspectlon Required7 ❑Yes �No Inspectlon Other Than Rough-In: 0 Ready Noa�Nill Catl
—( ^�' o,� You must call the inspedor when readyl Date Ready.
I certify that I am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
i�K �bo'�.
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Contrador License
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Mastar Electriden or Powrer Limi[ed
License Number
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