P - 76038'7 REQUEST FOR ELECTRICAL INSPECTION
1� 1 O�- 0 6 6 8� Minnesota Board of Electricity _�, ;
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricfry.state.mn.us
D@scribe -usirtg the back of the white copy ff ne���ne ��y���st: S SUJ i i'CH
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I GENERAL FEES Outdoor Liahtina Standard a(� $1
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device ar Apparatus @ $.50
ADDITIONS TO THE GENERAL FEES
8aom
TIOFI MAY BE
� i�l � I� 111�! ILI� ��I II �1 �I �I � III II ill I IIW
17`1�70668
Fee
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over
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Untt @$80
Additional Ins ction Tri s $20
Investigative Fee
Reins ction Fee @ $20
TOTAL FEE s. e d
(minimum total fee is $20)
THI9 APEA FOR 4VSPECTORU3E ONLY
I hereby certHy that I inspected the electrical installation da5cribed herein on the dates stat�:
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�� Rough-in Inspection Required9 ❑ Ye $] No Inspectlon Other Than Rough-In: [�Ready Now OVdill Call
�
gj � 4/��' I You must call the inspector when readyl Date Ready:
I c:�rGfy thai I am the Ll LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elecVical work at
IN9TR11CTIONS OP1 BACK OF VELLOW COPY BOARD OF FI.ECTRIfITV fnPV FRJiMiMY15 R � �nnd