P - 75232/j REQUEST FOR ELECTRICAL INSPECTION ���{
2� 16 7����# � Minnesota Board of Electricity
�7� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
"l �� � (651) 642-0800 TTYlMRS 1-800-627-3529 www.electriciry.state. .
Describe -using the back of the white copy ff nec�sary - the work cover� by this request:
� 6 I.QS �, — — �
GENERAL FEES Ou[door Liahtina Standard C�D $1
0 to 400
401 to 8�
Above 8
CIRCUITS, CIRCURS OF LESS TH,4N 50 VOLTS
Each System Device or Apparatus @$.50
ADDRIONS TO THE GENERAL FEES
MULTIPAMILY DWELLINGS (PER UNITI
Manufactured Home Park Lots
IIVSTALLATION MAY BE ORDERED
���������I�� �������N ����I ���IC��� 0� ��
21678842
Fee
�
over
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
AddiGonallns on Tri $20
Inv�sflgative Fee
Reins 'on Fe.� $20
TOTAL FEE
(minimum total fee is $20) (� ✓
7 WS A!@A FOR PISPCi: fIN2 USE OMX
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I hereby cerl(fy that I inspeded the etectrical i�IlaHon d� herein on the datea smted:
!�OR t)F�;CE L'$E Lv
��D JUL - � 2001
���`��/� � �
��' Rough-in Inspecdon Required? ❑ Yes �f�o IrtspecUon Other Than Rough-In: � Ready Now �10f�1 CaII
��� V 1 Yau must call the inspector wrt�en readyl Date Ready. `"
I certify that I am the �ICENSED COMRACTOR ❑ COMPANY ❑ OWNER and hereby request ins�ction of the electrical vrork at
Job Site Street Addr�s City
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/ Company
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�o (2) Phorre Numbers Includi
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Master Electriden or Power I
License Number
n (Z) Phone Numbers Inctudi
-(�20� )