P - 75935r
1-990���3
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D�cribe -using the back of the whRe copy if n�
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GENERALFEES
Above 200 Am ere a$10
AU1RM, COMMUNICATION, REMOTE CANTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Each AddiUonal Untt a[�. $25
Retrofit
REQUEST FOR ELECTRICAL INSPECTION � �
Minnesota Board of Electricity
1621 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1�00.627-3529 www.edectricidy.state.mn.us
�- the vrork cover� by this requ�t:
ti L � 1 - —1---�'""1- �l 8" � �
Outd�r Liah6na Sfandard (a� $1
II�I II III II lu II I�I II ��I I) III I� III II III �� I�
19906338
ONE & TWO FAMILY DWELLINGS, EACH UNR
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Ins{�ction Trips Each DwelGr�g Unit �$80
Additional Ins 'on Tri $20
Imestlgative Fee
Reins 'an Fee $20
TOTALFEE �
(minimum total fee is $20) ei
TM9AFE! FW2PISPECTORUgUO.Y
I hareby certlfyU�at I Nspeded the elechicel U�tellatlon desalbed herein on Ute dates s�ed:
F4R OFFICE USE ONIY
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��� Rough-in InspeGion Requiredl ❑ Y� o IrrepecNan Other Than Rough-In: 0 Ready Now WIA Cell
Sp� ��� You must call the inspector wfien ready! Date Ready:
I certify that I am the �LJCENSED COIdTRACTOR ❑ COMPANY ❑ OINNER artd hereby request inspection of the electrical vuork at
Job 3lte Street Address Cfty
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Township �on Range Fire No. Counry
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OwnedOxupant Name Please Provide Two (2) Phorre Numbeis IncludNg Area Code
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Anoka, MN
c:omraaor ucerise wumner nnaster raeandan or P
��Gl�%� � u��N�
g InstaOatlon)
�tellatl Please Provlde Txro (2) Phone Numbers
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