P - 78473REQUEST FOR ELECTRICAL INSPECTION
1����- 2 5 9�7 Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
• (651) 642-0800 i'TY/MRS 1-800-627-3529 www.electriciry.state.mn.us
� NEW C� REMODEL ❑l�DDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by tnis request:
Traffic Sipnal Standard
401 to 800
Above 800
urcwi i s � rttutrc� Transformer I Power Su I for Si ns I Outline Li h6n $5
0 to 200 Am re $5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 2(!0 Am re $10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips E�h Dweliing Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS AAdifinn�l Incrorfinn Trinc � a�n
I IhHMILT UWtLlIN6S rtrc urvi i � � TOTAL FEE
3 to t2 units @$50 Per Unit (minimum total fee is $20) ,� ,'�J' �
EaCh Additi0nel Unit �$25 THIS MEA Fpi IISPECtOR USE OfIY
I hereby certify tliat I inspecled the ek�ctrical insiallation described heiein on Uie dates sfaBed:
OTHER ADDITIONAL FEES Sy �t ,//•/�j _ o�
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R uest Date: Rough-in Inspection Required'? O Yes Inspection Other Than Rough-In: dy Now ❑ VWI Call
You must call the inspector when ready! Date Ready:
I certify that I am tt�e ''�LICENSED COhITRACTOR � COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Sile Address (Street Bou, a Route No.) CitY Zip Code
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Name
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Power Supplier Address
�any Name C �ntracta Lic
�ville Hedtin � Hf�:, �r:c, :
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u ac or, pa a Owner ing Installation)
BACK BOARD OF ELECTRICITV COPV
Lioense I�mber
EB-00001M14 8.1.2002