P - 76040I 1 7 8 7 O 9 O � REQUEST FOR ELECTRICAL INSPECTION
� � Minnesota Board of Electricity i
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55704
f (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
DesCribg -�sir�7e back of the wh8e copy'rf ne�� �he v�� ��,by �i��8t; ��� � TC H
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uNMUNICATION, REMOTE CONTROL, SIGNALING
C4RCUITS OF LESS THAN 50 VOLTS
ivstem Device or Aa�aratus na. $.50
Mile
1Y BE
Outdoor Lighting Stand
Traffic Sianal Standard
� Transformer I Power Supply for Signs I Outline Lighting @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwrelling Unit @$BO
Additional Insaection Trios C� $20
IF
TOTALFEE e�t10
total fee is $20)
that I inspected the el�trical instelladon tl�cribed herein on the dafes steted:
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�' Rough-in Inspection Required? ❑ Ye �] No Inspection Other Than Rough-In: �2eady Now ❑ Will Catl
8114646
You must call the inspector when readyl Date Ready:
I certify that I am �he L� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at