P - 76116REQUEST FOR ELECTRICAL INSPECTION
1� 1� 1- 0 5 9�3 Minnesota Board of Electricity �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-500-627-3529 www.electricity.state.mrz.us
DesCii6e -usirtg the back of ths+�whfte copy'rf ne�e��ne ��ea�y�,;��c; ��W � TCH
K I
GENERAL FEES Outdoor Lighting Standard @$1
SERVICES I PDWER SUPPLIES Traffic Sianal Standard (a� �5
JMBqUN1CATIQN, REMOTE CONTROL,
GRCUITS OF LESS THAN 50 VOLTS
iVStem Device orApparetus na $.50
5 per Fixture
Boom (a� $4C
Mile
IIIII IIIu�IW�III�����ll�l III�
�I III I IIII
17870593
Supplemental Fee @ $ZO
Transfortners u to 10 KVA a$10
Transfortners over 10 KVA a$ 20
Transformer / Power Su I for SI ns / Outline Li h8n $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$BO
n
total fee is
1 hereby cerMy that I inspected the elecUical inshallalion describ� herein on the da0es stated: �
IF NOT COMPLETED WITHIN
� �u� �v i � �. �
�' Rough-in Inspection Required9 ❑Ye� �] No Inspection Other Than Rough-In: [�Ready Now ❑Wi0 Call
8%�.�r%�Gtl
You must call the inspector when readyf Date Ready:
{ cer� that I am the [� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
.ioe s�e sa�t aadre� �+ry ' T}L M h! .. ;��
1050 k!E GAFeI7Ehlt1 AtlE
�
.{�i �T��°� �
��
I A{�OKA
Please Provide Two (2) Phone Numbers
\ / � �
c:onvactor ucense Number master Eiecmcian or P
C�'1FiF'OFiATI�]h�l C�°t Q08$,:i ��enseNumber
��L ROADqB�S��hlf ��FA�lLq I"Ihl 5Si14
�r or Owner Pertorming Installation) Please Provide Two (2) Phone Numbers I
�6'�� b��s—�911 � �
,���o� o��o��«,��Te,,.�r�.,��