P - 78124REQUEST FOR ELECTRICAL INSPECTION
1� 5 9 p- 2 41 � Minnesota Board of Electricity
� ( 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
C� S"( �� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW MODEL O ADDITION ❑ REPAIR Describe -using tl�e back M the white copy'rf necessary - thpe wo�rk �c�overed by this request:
� CoS � - �� �%"��l 0 OJ�
GENE L f S Outdoor ' htin Star�dard E1
SERVICES I POWER SUPPLIES Trafic S' nal Standard $5
0 to 400 Amcere � E25 Sunnlmm�ntal Faw kl 4�(1
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
THE GENERAL
3 to 12 Units � S50 Per Unft
Exh Additional Unit Q E25
OTHER AD
Lighting Retrofit (a� E.25 per f
Center Pivot Irtioation Boom•
� Transfortner / Power Supply for Signs I Outline Li�hting @ s5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
InGudes the Service �dlor Power Supply up to 500 Amperes, All
Grouits and Two Inspection Trips Each Dwelling Unit @ f80
Fee
(minimum total fee is $20) � �CU '
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�..�.cv� IxY�' � � If� d1E CkCdIG� �II��Ip11 �1� �IBfd11011 tl1E d2p5 $�:
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Rflquest Date: Rqrghin Inspecbon Requirod? ❑ Yes No inspection Other Than R
` r_� � ough-In: ❑Ready Now I Call
L � �6 You must call ihe inspecta when ready! Date Ready:
I certify that I am 1he�TCENSED CONTRACTOR OCOA�ANY ❑ OWNER and hereby req�st inspection af tlie elec4ical work at:
.�-- .............o....w...n..rrcaiam�urr BOAFipOFELECiFiICT'CAPV EB-00001M74 8.1.2002