P - 75971REQUEST FOR ELECTRICAL INSPECTION '
I � _ � � �' � 4, � � � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electvicity.state.mn.us
Describe -using the„ of thb w, copy'rf necessary - the wo co re�i b is r�u�t: q/�,
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SUPPLIES
0 to 400
IMMUNICATION, REMOTE CONTROL,
CIRCURS OF LESS THAN 50 VOLTS
iystem Device or Aoaaraws C1a $.50
3to12
rigation Boom
Home Park Lc
Standard
J_ Transformer / Poxrer Supply for Signs / Outline Ughtir�g @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Irtclud� the Service andlor Power Supply up to 500 Amperes, AII
Circuits and Two Inspectlon Trips Each Dwelling Unit @$80
Additional Inspectlon Trips @ $ZO
Inv�ttpative Fee
total fee is
I hereby certlry U�at I imspeded fhe elechical ir�s�lla6on desm'hed herein on tlre dates sfated: I
Lrnis �NSTA��ATIVN MAY BE URDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS _�
FQR OFFICE USE ONLY
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You must ceA the inspec�r when readyl Date Ready.
I certidy that I am the CFSfSED CONTRACTOR � COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Add�ess
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Lioense Number
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QiSTRUCTIONS ON BACK OF YELLOW COPY BOARD OF ELECTRICIIY COPV - . cq-mfnnt,��5 a� �nne