P - 75678REQUEST FOR ELECTRICAL INSPECTION '
�� 0 4, ����� � Minnesota Board of Electricity I
1821 University Avenue Suite 5128, Saint Paul, Minrresota 55104
-'� (651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
D�cribe -using �a back of the whfte copy'rf necessary - e work covered by this requ�t:
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GENERAL FEES Outdoor Lig 'r�g Startdard @$1
SERVICES / POWER SUPPLIES Traffic Signal Standard @$5
0 to 400 Amnere CrD $25 SuPPlememal Fes @$20 __
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Apparatus � $.50
ADDITIONS TO THE GENERAL I
Home Park Lots (
�ehide Park Sites
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��40�787
ONE & N/0 FAMILY DWE
Includes the Service andlor
Circuits and Two Ins�ctlon
Additional Irts lon T
Imestlaative Fes
y up to 500 Amperes� AII
Each Da�ellirtg Un(t (a� $80
(minimum total fee is $20) � �Q �
nre ar�n wn ws�croa u¢ aar
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I hereby cerUfythat I Inspeded tlre electricel hwtaVadon d�al6ed herein on fhe dates s�ted:
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FaH oFFicE use o�,�v
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�� Rough-in Inspectlon Required7 ❑ Yes o Inspectlon Ofher Than Rough-In: 0 Ready N Ca➢
�� ��'� � You must call tlie inspector vvhen readyl Date Ready.
I ceRify that I am the I� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspecfion of the electrical work at
Job Site Street Address �`� � CKY� ^��
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MaiMg Address (COntrector, Company or
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trardor Licer�se Number Mester El�trician w Power Limi6a
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Please Provide Two (2) Phorre N�nnbera Including Ar
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