P - 75921REQUEST FOR ELECTRICAL INSPECTION t
1����� 3�� � Minnesota Board of Electricity i
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
E (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Desaibe -usirtg�l% backI of the white copy'rf necessary - the work cover� by this request: r L
` � � l '�f% ln/1 C� �} 1' � Y' Ir"1 �i 1 / S'T �-{�fa ['�
0 to 400
)MMUNICATION, REMOTE CONTROL,
CIRCUITS OF LESS THAN 50 VOLTS
ivstem Device or Aaaaratus C1a $.50
3 to 12
Home
Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circwits and Two Ins�Ction Trips ' Each Dwel4m,� Unit @$BO
Addidanal Inspec�on Trips @ $20
InvesHpative Fee
total fee is
� herebY cerdlY that � UusP�ed fhe elechiml h�0adon desaWed
Se Bo I� 'on $20 S_L;�^p L
S Ins on @$30 per Hour °�D�^B^"�D ��
S 'al Ins 'on $.31 per Mile
TH131NSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
FQ#i OFFICE USE ONLY
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��' Rw h-in Ins
g pectlan Required? e�(Yes ❑ No Inspec4ion Other Than Rough-In: Ready Now ❑ WiA CaII
��� � � You must call the inspector arhen readyl Date Ready.
I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the el�trical work at
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.omoanv or ner Performina InstaVa
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unber Master Electridan ar P�
� Uce�e Number
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3 Provide Two (2) hone Numbera I
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