P - 760001-787-058 5�
6ack of the white copy if r
GENERALFEES
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity ;
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectriciry.state.rrtn.us
��1e`��"i a�by�'���'S SWITCN
CfRCUITS OF LESS THAN 50 VOLTS
3ystem Device or Apparatus @ $.50
� ADDITIONS TO THE GENERAL FEES
@ $50 Per Unit
�al Unft @ $25
Traffic Siqnal Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dweliing Unft @$80
Fee
total fee is
�
that I inspected the el�trical installation described herein on the daf� steted: I
Hour °w�°'"�vm°"ID
Mile
4Y BE ORDERED DISCONNECTED IF NOT
I II� �A1 u I I�N� II I
� III�II�I II ��I�llllllll
17�70�85
��
�
/�����
�o -06 �
MONTHS
""'�' Rou h-in Ins ection Re uired? ❑Ye �No Ins
� j��`Q� 9 p q pection Other Than Rough-In: [�Ready Now � Will Call
You must call the inspector when ready! Date Ready:
l artify that I am the C�] LICENSED CONTRACTOR ❑ COMPANY p OWNER and hereby request inspection of the electrical work at
Id3TRUCTIQNS QN BACK OF YELLOW COPV BOARD OF ELECTRICIN COPY FR-nMmt n.�5 n � �nnn