P - 789401-6�1-657 8
❑ NEW �REMODEL 0 ADDITION
r .. "��i � n
0 to 400
401 to &
Above 8
:UITS � F
�REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-080011YlMRS 1-800-627-3529 www.electriciry.stafe.mn.ur
REPAIR Describe -using the back of the white copy'rf necessary - the work covered by this request:
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOL7S
3 to 12 Units @ a50 Per Unit
Each Additional Unit �? $25
�III �I II� II ��I II ��I II f�) II I�I I� II) I� III 11� I�I.
16016578
Traffic Si nal Standard 35
Su mental Fee $20
Transfortners u to 10 KVA $10
Transformers over 10 KVA $ 20
Transfortner / Power Su I fw Si ns I OuUine Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes fhe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @ S80
TOTALFEE
(minimum total fce is $20� �—� . �j�
iHISARFJ� FOR INSPECTpi USE pLY
I herebY oe�9ty thaz! in�fec6ed the elecCical instaNaEOn described herein on the dales sf�ed:
�-6�
:=� �3 � -� c. c. 3"> ,.
� �
.� o� - c�S3�6 �- 71 � �S"t�
O f
Requgst I�ate: Rough�n Inspectlon Required? Yes ❑ No huupection Other Than RougMln: ❑Ready Now Wfll Call
�.� �C--� — You must call the inspecta when ready! Date Ready:
1
1 c�ertiy that 1 am tt�e 0 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and he�y request inspectbn of ttie electrical wo�lC at: