P - 76120p REQUEST FOR ELECTRICAL INSPECTION
1�� v�- 0 6 5 0� Minnesota Board of Elecficity _ i
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 T'fY/MRS 1-800-627-3529 xnvw.electricity.state.mn.us
DesCribe -using �Ek 6a`ck of the white copy 'rf n�� �ne �� ���py �q���c° S 54J I 1'CH
)IUth7UN1CATI0N, REMOTE CONTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
i�ern Device or Apparatus @ $.50
� ADDITIONS TO THE GENERAL FEES
3M
tNST�►L.LATION MAY BE ORDERED
II��IuII�1II�I�IIUTA�uIIIUWI lul�ll
1787U6'�
Traffic Siqnai Standard
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Suppty up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$BO
AddiUonal Insoecbon Trips (�a. $20
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total fee is
� hereby ceAi(y that I inspected the electrical installa6on describ� herein on the dates sfated: I
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1 WITHIN 12 MONTHS
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I U�' Rough-in Inspection Requfred? ❑ Ye� � No Inspectlon Other Than Rough-In: [�Ready Now ❑ WIII Call
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� You must call the inspector when ready! Date Ready:
I s�rkfy that I am fhe L�1 LICENSED CONTR,4CTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
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Utllity Address
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Please Provide Two (2) Phone Numbers
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ise Number Master Electriclan or P
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