P - 78168/� REQUEST FOR ELECTRICAL INSPECTION
1= 5 51 �} �� Minnesota Board of Electriaty
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
EW�O ftEMODEL O ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
AWRM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Exh Svstem Device or Aooaratus � 5.50
3to12
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15514433
Su lemental Fee S2(1
Transfortners u to 10 KVA $10
Tr�sformers over 10 KVA $ 20
Transformer I Power Su for S' ns / Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, Ali
Circuits and Two Inspection Trips Each Dwelling Unit @$80
TOTAL FEE I _ %"� iI�
(minimum total fee is $20) ��1��/ `�
TMS AREA FIXi INSPEGTOR USE ONLY
I hereby cerAry ihat I inspec0ed the electrical installation described hereio on tlie dates sfaled:
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IT COMPLETED WITHIN 12 MONTF
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Req � te� Rough�n Inspection Required? ❑ Yes Inspedion Other Than Rough-In: y Now p V1rll Call
�� `7 You musl call the inspector when ready! Date Ready:
I certiry that I am th� ICENSED CONTRACTOR ❑ COMPANY � OWNER and hereb
request inspection of the electrical work at:
Job Site Address (Street, Box, or Route o � Ci �` Lp Code
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ON BACK OF YELLOW Q6PY ' BOqRp OF ELECTRICT' COPV ... E 4 e. t.
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