P - 75679REQUEST FOR ELECTRICAL INSPECTION '
2� 0 4, � c� �� 7 � Minnesota BoaM of ElecVicity �
1821 University Avenue Suke S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Descdt� -using the back of the white co 'rf necessary - the work covered by is request,
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I SERVICES I POWER SUPPLIES
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCURS, CIRCUITS OF LESS THAN 50 VOLTS
Each Addfional Unft Q $25
OTHER ADDITI01
Liahtirta Retroftt C�a. $25 aer Fndure
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Traffic Sianal Standard
ONE 8 PNO FAMILY DdVELLINGS, EACH UNIT
Inctudes the Service and/or Power Supply up ro 500
Circuits and Two Inspection Trips Each DweO
Addfional Inspection Trips @ $20
� Imestiaative Fee
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$80
TOTALFEE �
(minimum total fee is $20)
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I hsreby certl(y tl�at I Nspected ths eleddcal 6�stallatlan d� herein on 6re dat� steted:
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FOR pFFFCE USE QNLY
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�� Rough-in Inspectlon Required? ❑ Y� Inspectlon Other Than Rough-In: ❑ Ready Now A CaU
�� � Z'�° You muat caU tlre inspector when readyl Date Ready.
I ceitity that I am the,�l LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby r�uest inspedion of the electrical work at
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WARo CL�C ?t1C So o C'•AO
Matling Addreas (ConUador, Company or Oumer PerformNg Ir�ate0adon)
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