P - 76146REQUEST FOR ELECTRICAL INSPECTION
� � � � � � 5 � 6 � Minnesota Board of ElecVicity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
�� a (651) 642-0800 TTY/MRS 1-800-627-3529 www.edectriciry.state.mn.us
D�.Mbe -using ck of fYro whRe 'rf ecessary - tha work covered by this reque.st:
� lo� 1—�1%� - ��S
GENERAL FEES Outd�r LigMin Standard @$1
SERVICES / POWER SUPPLIES Traffic8innal Standard (iil $5 ,
401 to 800
Above 800
;UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$•50
ADDRIONS TO THE GENERAL I
fIFAMILY DWELLINGS (PER UNIn
3 to 12 Units (m $50 Per Un(t
Home Park Lots
ALLATION MAY BE ORDERE
IIII UUI II��I IIIII II�� II�O IIW I�IO �� I�
�0245064
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circufts aml Taro Inspection Trips Each Dweltim� Unit @$80
Addfional Ins 'on Tri $20
Imestigative Fee
Reins on Fee $20
TOTALFEE �
(minimum total fee is $20) �
7M9 RFffA FOR N6PECIOft USE 0lbY
I hereby certlty that I Ir�apeded tlle electrlcal hretallatlon d�d herein on the detea s�:
�
naa
.. . a - - � --- -
T T�` ,
o��
'-COMPLETEQ 1MTH11�12 eAONTHS
FOR OPr'ICE USE OFlCr
,���� � /�f ��
�� Rough-fn Inspedion Requlred9 ❑Yes �No Inspection Other Than Rough-In: � Ready Now�WN Cell
/� � 1.7�0 You must cell the inspedor when readyi Date Ready.
rs-�
I certify that I am the,�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspedion of the electrical work at
Job S(te Address �° CKy
�� V � V� �� l
Township Secdon Range Ffre No. CouMy
� l�.) �
°�`�`�Oc`rwPent Weme Piease Provtde Two (2) Pho Nwnbers Indud'i� Aree Code
`+'rY' 1��11�. ��"��� ��- (a3�S��-��e�� )
0
masmr eier.maan or
Li�nse Niunber
\ �