P - 76119REQUEST FOR ELECTRICAL INSPECTION
1�� O�- 0 5 6 9� Minnesota Board of Electricity _;
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using theR+�k of the white copy if ne����na ����e�by�,���sr, � SW I TCH
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GENERAL FEES Outdoor Lightin Standard @$1
SERVICES I POWER SUPPLIES Traffic Sianal Standard Cal $5
>MB�UWICATION, REMOTE CONTROL, SIGNALING
GRCUITS OF LESS THAN 50 VOLTS
3 to 12 Uni� @$50 Per Unit
FEES
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unft @$80
AddiUonallnspection Trips @ $20
Investiaative Fee
total fee is
I heraby cerMy ffiat I Inspecled the electrical InstallaGon described herein on the datas stated: �
ecial n � $30 r Hour
eCfal Inspec8on @ $.31 �er Mile
N�I$TAtLATION MAY BE ORDERED DISCONNE�
I�I II I� u I� II I� p lu ��(I III I��II II III I UII
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_D WITHIN 12 MONTHS
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�� Rough-in Inspecdon Required? ❑ Ye� �] No Inspection Other Than Raugh-In:
s f� 4J�� C�Ready Now OWill Call
You must call the inspector when ready! Date Ready.
{ c�Ttify �at I am the L�1 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
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Piease Provide Two (2) Phone Numbers
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dnr/Compan Name
E�IT ELEG�1'FiTC COF:F'OFiAiTGh!
I��ess Gontractor, Company or Owner Pertormir
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rised Slarorire (Contrector or Owner Perfortnina In
Maste� Electrician or
License Number
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Please Provide Two (2) Phone Numbere
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Area Code