P - 76225REQUEST FOR ELECTRICAL INSPECTION
� � � � � � 2 � � a Minnesota Board of Electricity
1821 University Avenue Suite &128, Saint Paul, Minnesota 55104
.: "'�� n (651) 642-OS00 TTY/MRS 1-800-627-3529 www.elecdricity.state.mn.us
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Descn'be -using the back of the white copy'rf necessary - the work cover� by this request:
�° 7�/ n i�� -,[ C� SS�e � � ir �7`s /rn �e Z- 7' i�rS
GENERAL FEES Outdoor Lighting Standard @$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Am�re @$25 Suaolemer�tal Fee (aZ $20
Above Z00 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCURS, CIRCUITS OF LESS THAN 50 VOLTS
Each m Device ar pa�aWs @$.50
ADDffIONS TO THE GENERAL FEES
3 to 12 Un'rts
Home
INSTALLATION MAY BE ORDERED
I Ifll II III il I�I ii iii II I� � III � III � I� �� I�
18202887
Includes the Service and/or Power Suppty up to 500 Amperes, All
CircuiLs and Two Inspectian Tdps Each Dvrelling Unit @$80
Addidor�al Inspec�on Trips @ $20
Imestivative Fee
ivia.rr� , 7-�-y
total fee is $20) , /
I herebY �ertlry that I InsPected the electrical U�stalla8on d�cn'bed neretn on tlre dat� s�ted: I
IF NOT COMPLETED WITHIN 12 MO�
F4�R O�FCE USE O�JLv
REC`D J UN - 6 2001
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��' Rou h-in I�s on R uired? ❑Yes ❑ No Ins
g pectl eq pection Other Than Rough-In: � Ready Now � WW Call
�—�` U% You must cell the inspector when readyl Date Ready.
I certify that I am the ❑ UCENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address �(�y
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Ucer� Number
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�oamer Performing Installation) Please Provide Two (2) Phorre Numbers Including Area Code
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