P - 76026REQUEST FOR ELECTRICAL INSPECTION �
T° 9����� 5 � Minnesota Board of Electricity
1821 University Avenue Sufte 5-128, Sairtt Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.res
D�sa/il� -using tlie b�of the white �py'rf necessary - the vrork covered by this rec{ue.st:
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GENERAL FEES Outd�r Liahtina Standard (�a $1
0
ZN}, COMMUNICATION, REMOTE CONTROL, SIGNALING
,UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
fIFAMILY DWELLINGS (PER UNIn
3 to 12 Units (m $50 Per Unft
Lats
�1LLATION MAY BE ORDERED
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19859156
Trar�formers over 10 KVA $ 20
Transfortner / Power Supply for Sigr�s / Outline LigMfn $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Irrcdud� the Service andlor Power Suppty up to 500 Amperas, Aq
Circuits and Two Ir�specUon Trips Each Dwelimg Unit @$BO
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total fee is $20) J e
I hereby ceitify fhet I inspeded the electrical IrtstaVatlon d�saibed herein on tlre dates ate�:
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COMPLETED WITHIN 12
FOR C!�FICr �.iBE QN4Y
''"""` Rough-in Inspection Required9 �Y� ❑ No Inspec6on Other Than Rough-in: 0 Ready Now �IVill Cap
���� s�� You must call the inspector when ready! Date Ready.
I certify that I am the �I.ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Addr�s ��y
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Cnnhactor / Company Name
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MaiOrtg Address (CoMrador, Company or Owner Per�
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aDation)
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ON BACK OF YELLOYV COPY BOARD OF ELECTRICT' CAPV
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Mas[er ElectriGan or Power Limited Technfcian
Liceree Number
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Two (2) Pharre Numbers Indudh�g Area Code
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FR_f111M1'IA_15 Rt �M1d