P - 79123''](''� REQUEST FOR ELECTRICAL INSPECTlON
1� 1�..J �-17 9�2 Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-0800 R51-800-627-3529 www.electriciry.state.mn.us
❑ NEW O RE �❑,ADDITION ❑ REPAIR De%�cri.-be -us g t the white� py if necessary - the work covered by this request:
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SERVICES I POWER SUPPLIES
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus (� $.50
31012 Units @ $50 Per Um
Each Addifional Unit @ $25
Ligh6ng Retrofit @ $.25 per Fi�ure
Center Pivot Imaalion Boom � S4(
Standard
Fee � $
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, AII
Circuits and Two Inspection Trips Each Dwelling Unit @$60
Additional Ins 6on Tri $20
InvesG a6ve Fee
Reins Gon Fee $20
TOTALFEE
(minimum total fee is $20) �
TMIS MEA FOR INSPECiOR USE p1v
I hereby certiry that I inspecled the elechical installation deuribed herein on the dates statetl:
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Req4est Date: Rough-in Inspection Required? ❑ Yes ❑ No Inspedion Other Than Rough-In: y Now � WWI Call
'p ���S ' You must call the inspeda when ready! Date Ready. .
' I certity that I am the �LICENSED CONTRAC�O ❑ COMPANY ❑ OWNER and hereby iequest inspecdon of tl�e electrical work at:
Job Sile Address (Street Box, w Route 1No j Zip Code
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IN87RUCTIONS ON BACK OF
nease rro�ce � wo ��� rnone ran
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ConVactor License NumbEr Master Electritia
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ning Instellation) Phone (s)
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BOARD OF ELECTRICITV CAPY
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EB-OOOOfM14 8.7.2002