P - 78157REQUEST FOR ELECTRICAL INSPECTION
1� 5 7 6- 3 9 5� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-08Q0 TTY/MRS 1-800-627-3529 >�lectricity.state.mn.us
0 NEW ❑ REMODEL ❑ ADDITION � REPAIR Describe -using the back of the white copy if n e work covered by this request:
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IMMUNICATION, REMOTE CONTROL
CIRCUITS OF LESS THAN 50 VOLTS
Ystem Device or Ao�aratus (� 5.50
3 to 12 Units
Each Additioi
Lighting Rehofit
CeMer Pivot Imi
Traffic Si nal Standard $5
Su lemental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns I Outline Li htin $5
� ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
, Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins tion Tri s $20
Investiaative Fee
TOTAL FEE I �
(minimum total fee is $20) p� Q--•
TNIS AREA fOR INSPECTOR USE OfYY
I hereby cerGfy that I inspected the electrical insfalla6on described herein on the dates stated:
S 121 IOS U00 $30 B� HOUf - exPineons�rooNeo — - oaTE
S ial ins tion $,31 r Mile
� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Request Date: Raugh�n Inspection Required? ❑ Yes No Inspedion Other Than Rough-In: Ready Now O Will Cail
� �(� You must call the inspector when ready! Date Ready:
I certiTy that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at::