P - 76085REQUEST FOR ELECTRICAL INSPECTION �'
1— 9 31- 0 6 6 0 Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55� 04
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy ff necessary - the work covered by this requ�t:
- - ��E.1J t+'1 A �
C�BERAL FEES Outdoor Liphtinq Standard C� $1
401 to 800 Ampere @ $50
Above 800 Ampere (a� $75
�UITS/FEEDERS
0 to 200 AmPere @ $5
A�ve 200 Ampere @$10
iM, CAMMUNICATION, REMOTE WNTROL
�UITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Un(is @
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�II II ul I) lu (� III II I� II I� I� III II III ����
19310663
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Servke andlor Power Suppty up to 500 Amper�, AO
; Circuits and Two InspecUon Trips Each DwelGng Unit @$BO
Addftlonallns onT' $20
Investi ative Fee
Rein 'on Fee $20
TOTAL FEE
(minimum total fee is $20) 30 , � �
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I he�BbY �ff thet i� tlre electrlral 6isffi�iun d� herein en the dates sffied: _.
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iISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
FOR OFF{CE USE ONLY
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��� Rough-in Inspectfon Requfr�iT ❑ Yes � No IrrspecHon Other Than Raugh-In: ❑ Ready Now �WN Cefl
� 1 J� Q� You must call the inspedcr wrhen readyl Date Ready:
I cefify that I am the UCENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request insp�tion of the electrical work at
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Please Pmv�e Two (2) Phorre Numbeis I
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reeNumber Nlaster DecMdan w P
�y Lloen� Number
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Please Provide Two (2) Phone Numbers
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