P - 78122c REQUEST FOR ELECTRICAL INSPECTION
1� 9 0� J o 0 � Minnesota Board of Electricity
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� (651) 642-OB00 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
�NEW ❑ REMODEL ❑ ADDITION REPAIR Describelusing the bac� the whit�e copy if necessary - _ vered by`Mis request:
SERVICES / POWER
ALARM, GOMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device a Apparatus @ E.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @ S50 Per Unit
Each Additional Unit � S25
Center Pivot
Outdoor
Transformer I Power Su I for Si ns I OuUine Li htin $5
��J ONE & TWO FAMILY DWELLIN�S, EACH UNIT
Includes the Senice andlor Power Supply up to 500 Amperes, All
Circuits and Txro Inspection Trips Each Dwelling Unit @$80
Additional Ins ., tion Tri $20
Investi ffiive Fee
Reinscection Fce (al 820
(minimum total fee is $20) I y� J�� I
iH15 MFA FOR INSPECTqi USE Of1v
I hereby certify Mat I inspected the electric� insfaqa6on described herein on the dates sfakd:
� � ���
w
� �
5 ial Ins Uon $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED NATHIN 12 MONTHS
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15905003 �
�a���E �� �° ��� �S �(o ,l�D� SC7
;eq Dffie: Rough�n Inspection Required? Yes ❑ No Irupection Other Than Rough-In: ❑Ready Now Will Call
� � ��% You must wll the inspector wh rea y! Date Ready:
certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of ihe electrical work at:
r � ower Supp�
� �� //
or Owner Performing InstjNatioi
�-�!��,��� �
ON BACK OF YELLOW COPY BOARD OF ELECTRICITV CAPY
� � � �
ise Number Mester EJectrician or Power Limited Technician
� 'cense I�mber �O
� /� %/� ��r/
Pr,one (S)
�- - -�"c?.�
EB-00001 -11 8.1.2002