P - 75778REQUEST FOR ELECTRICAL INSPECTION
1�� 5 9� 7 01 � Minnesota Board of ElecUicity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
e (651)642-0800/`FY� 1-800-627-3529 www.electricity.state.mn.us
Describe,-u�ing the backpi the arttite copy if n�ry - the arqrk cove by u�t: �, �
:UITS / FEEDERS
o co zoo �r�re @ �
Above 200 Ampere @$10
2M, COMMUNICATION, REMOTE CONTROL,
�UITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to
Home
ecial Inspectlon �$.31 per Mile �
INSTALLATION NIAY BE ORDERED
I Uu u �I II II) II III II III II lu (I I� II I� �� I�
19597012
Fee
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Suppty up to 500 Amperes, All
Cirariis and Two Inspecfion Trips Each Dwelling Unit @$80
Additlonal Ins 'on Td $20
Investigative Fes
Reins 'on Fee $ZO
TOTALFEE
(minimum total fee is $20) �
naga�nr�on
I hereby certUy Uwf I� the elecMml tr�slaVaflon d�d here6i on fhe dates a�ed:
IF NOT COMPLETED WITHIN 12 MONTHS
FOR OFFICE USE ONLY
�D 01�-60��7�
° Rough-in Inspedtan R�uUed9 ❑Y� No U�specUon Ofher Rough-1 • y Now OWID Ca0
You must caU the inspedor when read Date Ready. '
I cer�fy thffi I am the SED GONTRACTOR ❑ CAMPANY ❑ OWNER and hereby request inspection of the electricel work at
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ON BACK OF YELLOW COPY BOARD OF ELECTRICITV COPV
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Master Electriden or Poxrer Lfm(ted �
Llcer� Number
xo (2) Phorre Numbera Includfig Area
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