P - 75938REQUEST FOR ELECTRICAL INSPECTION
1� 7��� 9 9 5� Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Sairrt Paul, Minnesota 55104
(651)642-0800TTY/MRS1-800-627-3529www.electricity.state.mn.us �� '
D�cribe -using ih back of the white copy'rf necassary - the work cove by this request:
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Above
;UITS, CIRCURS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
TIFAMILY DWELLINGS (PER UNIn
3 to 12 Units @$50 Per Unit
Each Additional Untt C� $25
Park Lots
Park Sit�
Traffic Sianal Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amper�s, All
Cirarits and Two Ir�s�on Tri� Each Dwellmg Unit @$60
Additional I� 'on Td $ZO
Investigative Fee
Reins 'on Fee $20
TOTALFEE �
(minimum total fee is $20) �O. J C�
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I hereby cerd(y that I i�pected the ele�al instaVednn d�ed hereln on the dates ate�ed:
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LTHIS INSTALLATION MAY BE ORDERED DISG�NNECTED IF NOT CONFPLETED WITHW 12 MONTNS �
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��' Rough-in Inspectlon Required? Yea ❑ Plo Inspecdon Other Than Rough-In: O Ready Now 4V� Cell
•%'%� /'� You must catl the inspector when readyl Date Ready.
I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electripl work at
Job Stte Street Add �py
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Name
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I STandard
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Contrador
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Master El�ridan or Power Limfted Techniclan
Liwnse Number
�65 � 484-8044 � )