P - 76326REQUEST FOR ELECTRICAL INSPECTION
��-1,'�,� � 3 0 0� Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
��� (651)642-0800TTY/MRS 1-8Q0�27-3529 www.edecfricity.state.mn.us
Describe -using thg back of the white copy if nec�sary - the arork covered by this request:
I SERVICES I POWER SUPPLIES
0 to 200 Ampere @ $5 ' � /�fsf/+a
Above 200 Ampere @$10
�MI, COMMUNICATION, REMOTE CONTROL, SIG
:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
TIFAMILY DWELLINGS (PER UNIT)
3 to 12 Units id. $50 Per Unit
Manufactured Home Park
LATION MAY BE ORDERED D
I�I � III II II� II III I I III II II I II �I 11 III �� I�
21293006
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Traftic Siunal Standard
ONE & TWO FAMILY DWEWNGS, EACH UNIT
Includes the Service and/or Power Suppty up to 500 Amper�s, All
Circuits and Two Inspection Trips Each DweQing Unit @$80
Additionallns 'onT' $20
Investigative F�
Reins 'on Fee $20
TOTALFEE y�,
(minimum total fee is $20) p�CJ
Tws a�a Fon wsaECroR usE aur
I herebvi certHv thet I insneded the el�icai I�tallaUon des�xibed herein on the datas sfetad:
VECTFD IF NOT COMRLETED WITHII
� RECD APR������Op�
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Date: Rough-in Inspedion R uired? ❑Yea o Ins
O' eq pectlan Other Then Rough-In: � Ready Now Will Cell
�� �1 ^� � You must wll the inspector when readyl Date Ready:
I cerMy that I am the J�LICENSED CONTRACTOR � COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Addr�s City I
31 � � • N� �r �
Township Section Range Fire No. �
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ar/Occuparrt Name ( - - Please Provide Two (2) P one Numbera Including Area Code
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Contrador License N Mas[er ElecMda
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or Owner Perfortning IristallaBon)
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