P - 75691REQUEST FOR ELECTRICAL INSPECTION �°' .
�_ 0 7�� 11 �� Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 wKnv.electricity.state.mn.us
Desai�'a =�'sing`the back of the white cop 'rf necessary - the work covered by this request:
(�%I��S � l>! C.�
GENERAL FEES Outdoor Lighting Standard @$1
SERVICES / POWER SUPPLIES Treific Signal Standard @$5
URS, CIRCUITS OF LESS THAN 50 VOLTS
Each System bevice or Apparatus @$.50
ADDIT10NS TO THE GENERAL FEES
Home Park Lots
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 50D Am�res, All
Circuits and Two Inspe�.fion Trips Each Dwelling Unit @$80
total fee is $20) � � cS� �S Z�
I herebr cerdfl� tl�at I U�spected the elediicel I�Vaticn des�bed here6� on the dafes
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I�I ��l IIAfI all� II�I II III IIIII II III 0� I�
l�Cro �i�����E�' 2OO'
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�� Rough-in Inspection Required? ❑Yea �l0� Inspection Other Than Rough-In: ❑ Ready Now�l Ca0
7�.�(� °7 You must call the inspactor when readyl Date Ready:
I certify ihat I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the el�trical work at