P - 77137REQUEST FOR ELECTRICAL INSPECTION
1� Q� ��� 7 Q � Minnesota Board of Electricity
, �� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTYIMRS 1-800-627-3529 www.electricity.state.mn.u!
Desaibe -using tlie back of the white copy if necessary - the work covered by t>his request: n�
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I SERVICES / POWER SUPPLIES
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Apparatus an $.50
Each Additional Unit @
Center Pivot Irrigation Boom �
Manufactured Home Park Lots
Traffic Siqnal Standard
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ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investipative Fee
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total fee is $20) 7
I inspeded the electrical installation descnbed herein on the dates stated:
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1 THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS �
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Date: Rough-in Inspection Required? es .❑ No Inspectlon Other Than Rough-In: � Ready Now�Will Call
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v� G S You must call the inspector when ready! Date Ready: -
I certiiy that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electricai work at
Job Site Street Address City
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Township Section Range Fire No. County
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Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
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Eledrical Utility Eledri�y Utility Address •
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Contrac or / Company Name Contrador License Number Master Eledrician or Power Limited Technician
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Mailing Address (Contrador, Company or Owner Performing Installation)
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Authorized� gnature (Contractor or wner Perfortning Installation) Please Provide Two (2) Phone Numbers Including Area Code
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