P - 75854REQUEST FOR ELECTRICAL INSPECTION
1� 9 2 3 a 0 3 0 � Minnesota Board of Electricity ,
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TlY/MRS 1-800-627-3529 www.electricdty.state.mr�.us
Desaibe -using6 �" l A^� mp C if/� work covere�i by this requ�t:
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:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus (d� $.50
ADDITIONS TO THE GENERAL FEES
TIFAMILY DWELLINGS (PER UNIn
3 to 12 Unfts @$50 Per Unit
Each Addifional Unit lad $25
Sih�
Traflic Sianal Standard
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includas the Service and/or Power Supply up to 500 Amper�, All
Cirailis and Tvro Inspection Trips Each Dwellirtg Unit �$80
Addfional Insa�on Trios C�¢ $20
total fee is $20) � �•�� �
I hereby cerHty that I mspeded the etectrical 6tstaVadun d�d hereN on the dates stated: I
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ALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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9 specd equired? ❑ Yes No InspecUon Oiher Than Rough-Ire � Ready Now Ca➢
��� /� �Q You must call the inspectar when readyl Dffie Ready.
I certity that I am the� LICENSED CONTRACTOR ❑�OMPANY ❑ OWNER and here6y request ins�tion of the electrical wark at
Job Site Street Addresa Cgy
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ric Co., Inc. � CA01715
or Oxmer Performing Inslallatlon)
Dri M �lewood MN 55109
�Gher P o �� ypIlatlan) Please
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�Y BOARD OF ELECTRICITV COPV
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mas�r r�ecmaan or
License Number
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