P - 78353�
1_ C n�°� Q n � � REQUEST FOR ELEC� RICAL INSPECTION
J l� O J ❑ Minnesota Board of Electrici
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTl'/MRS 1-800-627-3529 www.electriciry.state.mn.us
❑ NEW REMODEL ❑ ADDIT�ON ❑ REPAIR Describe -using the back af the white copy ff necessary - the work covered by this request:
i •- i
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
$50 Per Unit
Unit @ $25
illll lllll lllll llll(Illll lilll illll �f� �� l�
15019896
Trafic Si nal Standard $5
Su lemental Fee @ $20
Transformers up to 10 KVA @$10
7rarisformers over 10 KVA a 20
Transfortner / Power Su for Si ns I OuUine Li hfin $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 Unil �$80
TOTAL FEE I �/ ��
(minimum total fee is $20) T�
TX5 MFA Fpi NSPECTpt USE OtIY
I hereby certiy Ihat I inspec[ed Ihe ekctrical insfallation des�ibed I�erein on the dates staled:
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�Requasc uace: Rough�n Inspection Required? ' Yes ❑ No Inspedion Other Th� RougtNn: OReady Naw Wfll Call
���� You must call the inspecta when ady! Date Ready
I certify that I am the �ICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of ihe elechical xrork at:
Job Site Addriess (Street, Bw4 w Raule No.) City Zip Code
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Standard Electric Co., Inc. CA01715
Mailing Address ( � Campany or Owner Perfortning Insfaqation)
2672 p wood Dr., Maple ood MN 55109
Authorized Sig Mractor, Com Y or ng Instelladon)
iNSrnuc- oF reu.ow corr eoiwo aF �crnicm coPr
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'ovide Two (2) Phone N
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u�se ra�ner
651-484-8044
� EB-00001M14 8.1.2002