P - 75230REQUEST FOR ELECTRICAL INSPECTION
�° o��°� 5 0 � Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104 ;
(651)642-080Ll-TfYlMR�.1-BOQ-627-3529 . ec 'city.sdate.mn.us
Describe -using the back of the whlte copy if necessary - work cover� by this request:
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ENERAL FEES Outdoo ' Ming Standard @$1
SERVICES / POWER SUPPLIES Traific Sistnnal Standard C�D $5
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCURS, CIRCUITS OF LESS THAN 50 VOLTS
Each Addfional Unft �
Retrofit Cd3 �.25 aer Fixlure
Includes the Seroice and/or Power Supply up to 500 Amperes, AO
Circuits and Two InspecUon Trips Each DwelGng Unit @$80
Additional Ins 'on Tri $20
Invesdgative P�
Rei� 'on Fee $ZO
(minimum fee is $20 � �
nusaa�nw usea�ar
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I herebY cerYfY Net I NsPected fha elec61ca1 Ureta➢atlnn desrn'bed hetein on the datea ata0ed:
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• FOR �fFICE USE ONLY
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��� Rough-in Inapecdon Required? ❑ Yes o InspecUon Other Than Rough-In• eady Wow O WiA CaA
��� You mu� call the inspector when ready! Date Ready.
I certify that I am th�LICENSm COMRACTOR ❑ COMPANY O OWNER ami hereby request inspec8on of the electrical wotk at
Job S/�,"O ��15/7 • ��/ �/d / �fi`/ ( _r��.f� . � i' � �
GOLDEN VALLEY HEATIN�a � AIR
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