P - 75750REQUEST FOR ELECTRICA�.. INSeECTION -�°'��.
� � � �� 3 6 3 � Minnesota Board of ElecVicity ,�,(�D� — (��(p �
1821 Universiiy Avenue Sufte 5-128, Saint Paul, innesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectriciry.state.mn.us
DesaII� -using the back of the white co y'rf - the work covered by is requ�st:
CN�N � 5'�v��"To /v� �� '` �� .�'/�'�ff�a�/�l 4�ev�
GENERAL FEES Outdoor Liahtina Standard C�D $1
I MUL
to
CIRCUITS OF LESS THAN 50 VOLTS
>vstem Device or Aouaratus id $.50
Mile
INSTALLATION
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18223636
Transformers over 10 KVA $ 20
Transformer / Power S I for Si ns / Outlirre Li $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Suppty up to 500 Amperes, M
Circuits and Txro Ir�spection Trips Each Dwellmg Unit (a� $80
Additional Ir�s on Tri $20
Irnesti ative Fee
Reir�s 'on F� $20
TOTAL EEE
(minimum total fee is $20) ° �
TM9Af��FCHPISPECTOR11gQ'dY � �/�
I heteby certttythat I h�peded the eledripl ira�Vatlan desa�bed herein on tlm dates slated:
IF NOT COMPLETED WITHIN
=oa �Fic= usE cxv_v
�� Rough-in Inspectlon Requtredl ❑ Yes o Inspecdon Otlier Than Rough-In:�teady Nowr ❑ Wm Call
�`� l D� You must ca0 tlie inspedor when readyl Date Ready:
I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address
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Township Sedton Range Fire No. CouMy�O��
OwnerlOccupant Nartre Ple�e Provide Two (2) Phorre Numbe�s I�ludh�g Area CAde
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El�trical �8�ity El�i�l umft,,Addr�s
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Contractor / Company Nama Contrac�or Lic�nse Number Master Elec6ician or Power Limited T�hnid
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Ma�irtg Addr�s (Contrador, Campanv or Owner PerfortNna Inslallatlonl
Ov� �(Lr�� /y,�' •
ontracror or Owner Pertortnirta I�
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