P - 76055REQUEST FOR ELECTRICAL INSPECTION
1��� 0� 3 2 9 0 Minnesota � ard of Electricity �/'� � ��� ;
1821 Univers' Avenue Suite S-128, Sairrt Pa rifi ta 55104
%� (651) 642-0800 TTY/MRS 1-500-627-3529 www.electricity.state.mn.us
D�saibe -using th back of the white copy'rf necessary - the work covered by this requ�st:
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GENERAL FEES Outdoor Lighting Standard @$1
SERVICES / POWER SUPPLIES __ , TraRc Sicmal Standard (�a. $5
to 800
CIRCURS, CIRCUffS OF LESS THAN 50 VOLTS
Each S rstem Devi� or A paratus $.50
ADDRIONS TO THE GENERAL I
MULTIFAMILY DWELLINGS PER UN
3 to 12 Units na $50 Per Unit
Reaeatlonal
I TH1S
FEES
HOUf
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19003292
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Pmver Suppiy up to 500 Amper�, M
Circuits and Two Inspection Trips Each DweWng Unit @$80
Additional InspecUon Trips @ $20
Invesdaative Fee
total fee is
I mspected the electrical insteVation descrtbed herein on fhe dates s�ed:
ontE
—/'2_ 2 ,.p�-'
a DATE �
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�re
)T COMPLETED WITHIN 12 MONTHS
-�ir r.� r�cc use r�:_:,
'�� Rough-in Inspection R�uh�i?�es ❑ No Inspedion Other Than Rough-In: ❑ Ready Now ❑ Witl Ca�
�� q�� ��� You must call the i�pector when readyl Dale Ready:
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I certify that i am e LICENSED CONTRACTOR ❑ COMPANY 0 OWNER and hereby request inspedion of the electrical work at
; Job Site Street Address C
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i Township Sectian Range Fire No. CouMy
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'� Owner/Occupard Name Please Provide Twro (2) Phorre Numbers Including Area Cade
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nber master tiectnc�an or
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