P - 75461�
REQUEST FOR EL�TRICAL INSPECTION ��°' "
1��� o� 4 0 4 0 Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TlY/MRS 1=800-627-3529 www.elecdricity.state.
p��� using the back of the whde copy'rf ne�essary - the work cover� bjy �this request:
� 1 t/� t YL \ � ►4 ��^�-e,�
GEN FEES Outdoor Lighting Standard @$1
SERVICES / POWER SUPPLIES Traffic Signal Standard (�a. $5
Oto4(
401 to
CIRCURS OF LESS THAN 50 VOLTS
Y
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Inciudes the Service and/or Power Supply up to 500 Am�res, All
Circufts and Two Ir�spectlon Trips Each Dweuir�g Und @$80
Additiomal Inspedion Tdps @ $ZO
� Imestiaative Fee
GS PER UN TOTAL FEE ) CJ7
Per Unit (minimum total fee is $20) /. J��
(0�$25 nus Foaw�crorsusEwnr
HER ADDffIONAL FEES
�5 rw3r FiYhira I herebvi cerdfir fhffi I f� tl�e electriral iretallatlon � he efi� tlre da� s�ed:
Hour
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1820404�
6.I—�_ _— �(G — • J ..�
�NECTED IF NOT COMPLETED WITHIN 12 MONTHS
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FC�R �wFiC� 1lSE ONLV �✓
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��� Rough-in Inspectlon Required7 �❑ No InspecUon Other Than Rough-I Ready Now �WAI Ca0
�� f � 7� ZQ8 � You must call the inspedor when ready! Dete Ready. �� l��r /Z� �
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY �OWNER and hereby request inspection of the electrical work at
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al Utility Elechical Utllity Address
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mascer tiecmaan or
License Number
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