P - 76037REQUEST FOR ELECTRICAL INSPECTION
1� 7 8 7� O 9 2 � Minnesota Board of Electriciry _
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.elecri-icdfy.state.mn.us
DesC�+be -using the back of t,he white copy if ne���ne'����y�ai��t' � S�1 T TCH
HVt�AUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
Fixture
�iall�pection $30 Hour
ecial Inspection � $.31 per Mile
iN$TALLATION RAAY BE ORDERED DISC
IIB�I�III���N�III�NNIII111IIIIIIIIII
17'�7092�
Traffic Sianal Standard
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Suppty up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Addi�onal Ins 'on Tri @ $20
Investigative Fee
Reins ction F� @ $20
TOTAL FEE � , .
(minimum total fee is $20)
THISARERFOR WSPECTOA USE 0lAY
I hereby certi(y that I inspec[ed fhe electrical instaVaGon desc�ibed herein an the da�.s s�ted:
� �6°E'e �
NECTED_IF NOT COMPLETED WITHIN 12 MONTHS
�o�c� -�s � ��
�' Rough-in Inspection Required? ❑Ye �No Inspection OtherThan Rough-In: [�Ready Now ❑Will Call
8/14/Gb
Yau must call the inspectar when ready! Date Ready:
I certilfyy that I am the L'�I LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
G19TRUi710NS QN BACK OF YELLOWI COPY BOARD OF ELECTRICITV COPY EB.OMMIA-16 n 1 9nna