P - 76312• REQUEST FOR ELECTRICAL INSPECTION
2� 9.-7 ���� Q � Minnesota Board of Electricity
�.7 �u niversity Avenue Suite 5-128, Saint Paul, Minnesota 55104
800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
D�aibe -using the back of the white copy if n - the work cavered by this r�uest:
GENERAL FEES Outdoor Liahtimt Standard na. $1
Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
Transfortner / Power Supply for Signs / OWine Lightl� @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amper�, An
Circuits and Two Ir�spection Trips Each Dwe�ing Unit @$BO
CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Unfts Co� $50 Per Unit
Sp�al I� ection @$30 er Hour
Speaal Inspecllon @ $.31 per MUe
THIS INSTALLATION MAY BE ORDERED
IIII�����I II��I ���I I��II �II�� �IIII�I�I��� ��
21399183
TOTAL FEE � � j� � ���
total fee is $20) O�I.J
electrical U�ataVatlon d�d herein on the dafes s�ted: I
D IF NOT COMPLETED WITHIN 12 MONTHS.
REC'D A�`R�'�'�'"`�1
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u�: Raugh-in Inspection Req�dred? ❑ Yes � I�pedion Other Than Rough-In:�dy Now ❑ WW Ceil
�`�I� You mu� ceq the inspedor when readyl Date Ready.
I certdy that I am the L�ENSED CONTRACTOR � COMPANY ❑ OWNER and hereby requegt ins�ction of the electrical wrork at
Job Site Street Address �, w _ 9 �/' � i _.
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�or Li��%� Master clan or,P\
License
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Please Provide Two (2) Phone Numf�rs I
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(� 7S�7-SU� )