P - 75842REQUEST FOR ELECTRICAL INSPECTION
1����_� 6 4 0 Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricify.state.mn.us
Describe - si� e back of���py If n - the work cove�; is request: �
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GENERAL FEES Outdoor Lighti Standard @$t
SERVICES / POWER SUPPLIES Traffic S' Standard @$5
0 to 4�0 Amaere (�a. $25 Suoolementaal Fee frD P20
I THIS
)MMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
ivstem Device or Aooaiaws id $.50
Pivot Irrivadon Boom
I�II rl II� II (�I II I�I II ��I II I� II �II II � U� I �II
18984641+
Trensformers over 10 KVA $ 2(1
Transformer / Poxrer Su I for Si s/ Outline LI hdn $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includa5 the Seroice andlor Power Suppty up to 500 Amperes, All
Circuiis and Twro Inspection Trips Each Durelling Unit @$80
Additional Ins 'on Tri $20
Investi ative Fe.e
Reir�s 'on Fee @ $20
TOTAL FEE � 1
(minimum total fee is $20) �7 �
TI1IS ARFA FOR RiSPECIOR USE O�Y
I hereby certlfy that I 6� the etectrical i�laVetlon desrn'6ed herein on fhs daUes stated:
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IF NOT COMPLETED WITHIN 12 MONTHS
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�°�,n _-/� � Rough-in Inspectlon Required7 �Ves ❑ No Insp�#on Other Than Rough-In: 0 Ready Now�Wi� Call
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��� ��� You must call the inspedor when readyl Dffie Ready.
I certify that I am the CENSED CON'fRACTOR ❑ COMPANY ❑ OWNER artd hereby request inspec.fion of the electrical work at
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