P - 76209—= REQUEST FOR ELECTRICAL INSPECTION -' °� <
2� 14 7� 3 61 � Minnesota Board of Electricity I�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
�a 1, ` (651) 642-0800 TlYlMRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy'rf necessary - the work covered by this r�uest:
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GENERAL FEES Outdoor Li htirtg Standard @$1
SERVICES / POWER SUPPLIES Traflic Sinnal Standard a�. $5
401 to 800
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Appaiatus @ $.50
ADDRIONS TO THE GENERAL FEES
Boom
Mile
I�II I� III (I III u lu II UI �I III �I lu II III �� I'�II
21473616
�j�7990 FAMILY DWELLING;
I udes the Service andlor Power
Circuits and Two Insp�tion Trips
total fee is
up to 500 Amperes, All
ach DweOing Unit @ $80
I frerebv certH that I inspeded the electricel his�llatlon described herein on ffie dates s�ted:
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IF NOT COAAPLETED WITHIN 12 Mi
�'I�C.� �I �'y� ��v 20�7
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��� Rough-in Inspecdon Required7 ❑ Yes �No Inspecdon Other Than Rough-In: � Ready Now�W�l CaU
(o L� �% �.,.
You must cell the inspedor when readyl Date Ready:
I certify that I am the �JCENSED COPITRACTOR ❑ COMPANY 0 OWNER and hereby request inspection of the electrical work at
Job Site Address City
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Number
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