P - 77267REQUEST FOR ELECTRICAL INSPECTION
1— 7 2 9�� L� 1� Minnesota Board of Electriaty
7821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
Ck,�� Q� (651)642-0800TTY/MRS1-800�27-3529www.e/ectricity.state.mn.us
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❑ NEW EMQpEn� DDI JQ ��,A� Describe -using th�� �the � c� ����� by this request:
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FEES
SERVICES / POWER SUPPLIES
GRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Each Additional Unit @ i25
Lighting Retrofit @ E.25 per Fixture
Center Pivot Irtiaation Boom �! S4(
Hour
Outdoa
�RE & TWO FAMILY DWELLINGS, EACH UNIT
Includes Ihe Service �dlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
TOTALFEE �
(minimum total fee is $20) p?0
THS MFA FOR M6PECTOR USE QlY
I haeby cerMy Mat I in�Cled Ihe dectrical i�fall�on desaibed hadn on Ihe da6es sl�ed:
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IIII I�N� III�I II�I Ilill IIIII IIIII IIIII �� �� ��- �� �
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1729581�
Request oate: Roupn-in �ns{,ecnon rtequirod? ❑ ves tr,specUOn other rnan Rouyn-�n: OReaay vw� cau
�� (�� Q� Yau must csll the inspecta when roady! pate Ready. .
I ceAify that I am 1he L�CICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of tl�e elec6ical woric at: