P - 78137�.-576-399❑8
❑ NEW ❑ REMODEL ❑ ADDITION
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�ENERALFEE
SERVICES I POWER SUPPLIES
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, ' nesota 55104
(651) 642-0800 T'fY/MRS 1-800�27-3529 e ctriciry.state.mn.us
R Describe -using the back of the white copy if nec e work covered by this request:
.
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2M, COMMUNICATION, REMOTE CONTROL, SIGNALING
;UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENER,4L FEES
i1FAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Per Unil
Each Additional Unil @ $25
OTHER ADDITIONAL FEES
Lighting Rehofit @ $.25 per Fizture
Center Pivot Irriaation Boom � S40 I
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MAY BE
IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII �� I�I
Traffic Signal Standard
Suoolemental Fee Cd S
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
TOTAL FEE I _ j")
(minimum total fee is $20) Q��
iH15 AREA Fd21NSPECip3 USE pJLV
I hereby certify that I inspected the electrical installa6on described herein on Me dates stated:
g-�-�-�Y
ECTED IF NOT COMPLETED WITHIN 12 MC
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15763998 �O�L'-�c���/ ��
Request Date: Rough-in Inspection Required? ❑ Yes Inspedion Other Than Rough-In: eady Now ❑ Will Call
��ZS'{Jy You must call the inspector when ready! Date Ready:
I
I certify that I am the �LICENSED CONTRACTOR 7 COMPANY ❑ OWNER and hereby request inspec6on of tl►e elecUical work at::
� ........ ... ....�.. � �.�..� � . vvr � ttl-U{1W 11�-11 tl.l. 2002