P - 75745REQUEST FOR ELECTRICAL INSPECTION
1� 9 T�� ° o�� � Minnesota Board of Electricity ,
��� � 1821 Universitp Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 T1YlMRS 1-800-627-3529 www.electricity.state.mn.us
Descn'be -usirig the back� h�te,eQ ff`Cil.���� 1�1 red by this�� �`�� —�� ��
a.� l�
� CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Each Additlonal Un� (�D $25
Retrofit
LLATION MIAY BE ORDERED
WIIIIUIIIIIIIuI�III�IUII�IIII���I�
191,30095
Traffic Sianal STendard
ONE & TWO FAMILY DWEWNGS, EACH UNIT
Includes the Service and/or Power Suppty up to 500 Amperes, All
Circui4a and Two I�pection Trips Each Dwel�m� Unit @$80
Addfional Ins 'on Td $20
Inv�ti ' e Fee
Reir�s 'on Fee $20
TOTAL FEE C _
(minimum total fee is $20) � ���
TM9AF�A WR PlSPECTORIIg OM.Y
I herebY �ertttYthat I inspe�d tl�e elecMcel h�taVatlnn des�xibed hetein an the detes stated:
fOR OFfiCE USE ONLY
12 MONTHS
�
"�""� Rough-in Inspedion Requlred9 ❑ Y� �No Inspectlon Other Then Rough-In: � Ready Naw �NM Cap
lQ` pZ �' o� You must m0 the inspector when readyl DaDe Ready.
F cer�fy thffi I am the .�UCENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby requast mspection of the electrical work at
Job Site StreeY Address �yty
I�kt� �oLt l�r��� (--r`�l
Tawneh�p n Range Ftre No. County
G�--`�
Owrter! t Natne Please Provide Two (2) Phorre Numt�re Induding Area Code
0.0 ������.ae �I�YiSOYI 6�57 �- ��� �
13562
'�
mascer r�ecmaan or
Ucense Nurttber
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AR OF EIECTRICT' COPV