P - 76170n REQUEST FOR EL-E�T��AL INSPECTION � '
r� — o���� 4 3� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Safnt Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-&27-3529 www.electriciry.state.mn.us
Describe -using the back of the whfte copy'rf n�ry - the work cover� by this requ�st:
�� 1 6r'T�
� GENERAL FEES Outdoor Lighting Standard @$1
S�RVICES /�UWttc �UPPLIES TraRc Stamal Standard i� �5
CIRCUIFS OF LESS THAN 5Q VOLTS
Unit @
� Su a �lemerital Fee (� $20
Transfortners u to 10 KVA $10
Transformers over 10 K1/A @$ 20
Tiansfortner / Power S I for Si ns / Outl'me LI htln $;
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Irtcludes the Service andlor Power SuPPh�p ���PB�, �
Cirwits and Two Ir�saection Ttios Each DuaeOina UNt 1a7�
Fee � $20
TOTAI
iimum total fee is
Fbcture � � � hereby cerUfy mat � ire�d the e��triml trislauatlon aes¢med h�n on
Hour
, F�P.OFFIf,E USEOIVLv
f�il � lll ll lil il �l li l� � l� ll �i Il f� �� l�
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�: Rough-in Inspectlon Required7 ❑ Yes No - Inspedion Other'fTmn Rough-In: 0 Ready Now CaA
� l � � You must cep tha in.spector when readyl Date Ready:
1 certify that I am the UCEN3ED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspe�tio►� of the eler,6ical work at
Job Site Street Add Cily =
r'I �-% 1 I �'��c/ l eC� i(�� �� ° � � � ��i
License N�nnber Master Electridan or
LJl.9 1 � Llcer�ae Number
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� InGuding Area
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