P - 76302' REQU�ST FOR ELECTRICAL INS ECTION �'
2� 1� 7� 4� 0� Minnesota Board of Electricity � / �
�'`° -° 1821 University Avenue Suite 5-128, Saiht'P�1, Min�esota 55104
- (651) 64P-0800 TTY/MRS 1-800-627-3529 www.elecrizcity.state.mn.us
Describe -using the back of the whfte copy 'rf ry- the work covered by this request:
Lc% o�ce� `E-' GC� G
GENERAL FEES .Outdoor Liahtina Standard C� $1
;UITS / FEEDERS
0 to 200 Amoere (
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Apparatus @ $.50
ADDffIONS TO THE GENERAL FEES
3 to 12 Units
Home Park
INSTRLLATION MAY BE ORDERED [
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21274600
Fee
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over
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Turo Ins�on Trips Each Dwelling Unit @$BO
Additional Ins 'on Tri $20
Imestigative F�
Reins 'on F� $20
TOTALFEE
(minimum total fee is $20) �
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I hereby certly fhffi I inspeded the el�hicel I�taVatlon des�bed hereln on Me datea stated:
REC'�R�v�lca`Y°`� 0 200�
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��� Rou h-In Ins on R uired? ❑Yes �No Ins
g pectl eq pecdon Other Than Rough-In: � Ready Now Will Call
� a'� You must call the inspedar wrhen readyl Date Ready.
I certify that I am the CENSED CONTRACTUR � COMPANY ❑ OWNER and hereby request inspection of tMe electrical work at
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MasUer ElecMcfan or Pouiaer
Lfcense Number
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