P - 76357REQUEST FOR ELECTRICAL INSPECTION
�— 8��� �� � Minnesota Board of Electricity J;
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 842-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
Descri� -using the back of the white copy'rf Pecessary - the work covered by this reque.st:
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GENERAL FEES Outdoor '_ 'nq Standard a�. $1
I SERVICES / POWER
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUffS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aaoaretus Ca) $.50
3 to 12 Units (d� $50 Per Unit
Each Addi�onal Unit @ $25
orH�aoomoi
Liuhtina Retrofit CrD. $.25 r�r F'octure
Mlle
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182�2812
up to 10 KVF
over 10 KVA
ONE 8 TUVO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, AU
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Rein 'on Fee $20
TOTALFEE
(minimum total fee is $20) ��=�
�T1119AREAF�IINSPCCfORU5E0MY /
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i ne�bY �, n� i mso�a me �ear� �e��anon a�t�re��t,e'daces sm�ea:
� NOT COMPLETED WITHIN 12 MONTHS
FUh OFFICE USE OFCt
RECD MAY 2 4 2001
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�� Rough-in InspecUon Required? ❑Yes �No Inapectlon Other Than Rough-In: ❑ Ready fdow,$,Witl Cell
�� y'�� You must ceU the inspector when readyl Date Ready:
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY � OWNER and hereby request inspection of the elecfical work at
Job Site Street Address � City +
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ToMmship Secdan Rar�ge Fl�e No. County A
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Oxmed Name � � Please Prov�e Taw (2) Pho�re Numbers Including Area CAde
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Elearical UtiUty Electricel Utillty Addrags
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mas�ar rreranc�n or
License Number
or
or owner Perro instananon) Piease Nrowae rwo �z� Nnone rvumuera i
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