P - 75967REQUEST FOR ELECTRICAL INSPECTION
L s� 3�� 7 7� � 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
Desaibe -using the back � wh' �copy'rf necessary - the cove requ�st:
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Above 200 Am re $10 Includes tl�e Service and/or Powrer Supply up to 500 Am�res, All
tM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwalling Unit @$80
:UITS, CIRCURS OF LESS THAN 50 VOLTS Add'dional Ins 'on Tri $20
Each m Device or Ap ratus $.50 Investigative Fee
ADDITIONS TO THE GENERAL FEES Reir�s 'on F� $20
TIFAMILY DVVELLINGS PER UN TOTAL FEE �
3 to 12 Units @$50 Per Unit (minimum total fee is $20)
Each Addfional Unit @$25 f�W AflEA FOR PLSPECIORI6E OMY
OTHER ADDI110NAL FEES
Lightlng Retroffi @$.25 r Fodure I hereby certity that I i�peded the electriwl insmllatlon d�d hereln on ihe da�es sia�d:
Cerder Pivot Irtination Boom al� $40 R01tliP1 �T�
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S Ins on $.31 r MUe
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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You must call the inspectar when ready! Date Ready:
I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Add
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Company Name f�--' Contrador Ltce�e Number Mas[er Electride
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( C !sC 2�}� 9
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2619 Coon�.apids Blvd,
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