P - 75923REQUEST FOR ELECTRi��C INSPECTION
2� o 0 7��� q, � Minnesota Board of ElecVicity � 4
1821 University Avenue Su'ite S-128, Saint Paul, Minnesota 55104 �
(651) 642-0800 TTY/MRS 1-800-627-3529 �vww.electriciiy.stade.mn.zrs
Describe -usmg the back of t�he �hite coPY if ne�sary - the rk covered by this est: ^ �J-
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� GENERAL FEES Outdoor Lig Standard Q$7
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Amoere na �25 s�,�,iRmRmAi F�, n a�n
� CIRCUITS, CIRCURS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
Unit @
Transformers over 10 KVA $ ZO
TransFormer / Power Supply for Signs / Outlirre Lightlng $5
ONE & TVdO FAMILY DWELLINGS, EACH UNR
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Ins�on Trips Eadi Devel�rtg Un(t @$80
Addi6'onal Insuection Tri�s f�a $20
TOTAL FEE
total f� is $20) �� � `�
I hereby certlfy that I inaped� the el�trl IrmtaVatlon d�a@ed hetein on fhe dates s�ted:
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
�r' FOR OFFICE USE ON�Y
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"° � Raugh-in InspecUon Required7 �Y� ❑ No Inspecdan Oticer Than Rough-In: D Ready No�1Nm Ca0
oYou must call fhe inspector when readyl Date Ready.
I cerbfy that I am e � LICENSED CONTRACTOR ❑ COMPAWIf OWNER and hereby request insp�tion of the elecfical work at
Job Slte Street Address
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BOARD OF ELECTRICT' COPV FR-nmmtn-�5 n t �'ma