P - 75698REQUEST FOR ELECTRICAL INSPECTION �
� � � � � � � � 6 � Minnesota Board of Electricity
a,� 1821 University Avenue SuRe 5-128, Saint Paul, Minnesota 55104
� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy if necessary - the wrork covered by this request: ���� ��� ����
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GENERAL FEES Outdoor Lighdng Standard �$1
SERVICES / POWER SUPPLIES Tra�c Signal Standard @$5
0 to 400 Ampere (�D $25 Supplemental Fee @$20 ___
CIRCURS OF LESS THAN 50 VOLTS
.Y DWELLINGS (PEI
Units [a� $50 Per Unit
Hour
I�� u III II W II II� II II� I� III � UI II UI �� I�
21176367
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuik and Two Insp�tion Trips Each Dwelling Unit @$80
Addfional Inspection Trips @ $20
Imestiaative Fee
TOTALFEE ��
toial fee is $20) � `�
I herebY �h'thffi I insp�ted tlre ele�ical insteliadon descafbed herein on tlre dat� si�ed:
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1 IF NOT COMPLETED WITHIN 12 MONTHS�,___�
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�� Rough-in Inspecdon Required9 �es ❑ No InspecUon Other Then Rough-In: ❑ Ready NoW/�4Vill Call
SJ�—' �/ You must call the inspedor when readyl Oate Ready.
I eertify that I am the �ICENSED CONTRACT�R ❑ COMPANY ❑ OWNER and hereby request insp�tion of the electrical work at
JobSite �3t� �°i�,h .5�: #� � c� �o�/e
Township Secdon Range Fire No. County
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OwnerlOccupa Plea� Provide Two (2j Phorre Numbers IncdudU�g Area Cade
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Eledricel U�� Electrical Utllily Address
IICe ,EIeG-f �i �
ontractor License Number Master ElecMdan or Pow�er Limlt� Techntden
��, �y 3� License Number��c�so �
1�.�-��I (� /�/ �� � 1
P��3� ��� � Phorre Numbe�s Indudh�g Area Code
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