P - 78270REQUEST FOR ELECTRICAL INSPECTION
1-� 4� 4� 4 �� � Minnesota Board of ElecUiaty
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-0800TTY/MRS1-800�27-3529 www.electricity.state.mn.us
O NEW O REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy 'rf necessary - the work covered by this request:
L1. 9_ ) !n � �A... �i l , �
tM, COMMUNICATION, REMOTE CONTROL, SIGNALING
;UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
fIFAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL
Lighting Rehofit � $25 per fixture
Center Pivot Imaation Boom � $40
II� NI� III� I�II! II�II IIIII II�I) �II� �� I�
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L4244081
Su lemental Fee p $20
Transfortners u to 10 KVA $10
Transfortners over 10 KVA $ 20
Transformer I Power Su I for Si ns I Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
InGudes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
Additional Inspection Trips @ $20
InvesGaative Fee
(minimum total fee is $20) � YQ�� �
iM15 AREA FOR INSPECTIX2 USE 011v
I hereby cer6fy tlwt I inspected the electrical install�on described herein on the da0es sfated:
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rc� ace: Rough-in InspecGOn Required? Yes ❑ No Inspection Other Than Rough-In: eady Now ❑ Will Call
DYou must call the inspeclor whe ready! Dffie Ready:
I ce' Uiat am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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IN87RUC'.JqS ON BACK OF YELLOW COPY . S BOARD OF ELECTRICT' COPY E&00007A-14 8.7. 2002