P - 76030REQUEST FOR ELECTRICAL INSPECTION ��`''�
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�� 0 3�� 0��1, � Minnesota Board of Electricity
1821 Universiiy Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TlY/MRS 1-500-627-3529 www.electricity.state.mn.zrs
D 'be -usir�g the ba of the white co 'rf n work cove b this est:
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Nmve 200 Am �ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGI
CIRCURS, CIRCUITS OF LESS THAN 50 VOLTS
Each S em Device or s@$.50
ADDRIONS TO THE GENERAL FEES
MULTIFAMILY DWEWNGS ER UN
3 to 12 Units @$50 Per Unit
Each Addfional Unit Q $25
OTHER ADDRIONAL FEES
Lighting Retrofit @ $25 per FoRure
Ce�er Pivot Irtiaation Boom id �40
xtion @ $30 per Hour
;dion @ $.31 �r M�e
J.ATION MAY BE ORDERED 1
I� u W u��� II III �� �I II ��) II II� � III u� I�r
203�0242
Transfortners over 10 KVA $ 20
Transformer / Poever Supply for Signs / Oudine Ughting $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andfor Power Supply up to 500 Amperes, All
CircuiLs and Two Inspa.fion Trips Each dweWng Unit @$80
TOTALFEE
total fee is $201
I hereby certify thet I Uispe�ted the electrical h�sta0atim� desdibed herem on the dat� stafed: �
IECTED IF NOT COMPLETED WITHIN 12
FOP, OrF;CE IiSE ONLv
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�f� Rough-in Inspection Required7 ❑ Yes o Inspedion Other Than Rough-In: 0 Ready N�AI Call
�� �i You must cap the inspector when ready! Dete Ready:
I certify that I am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request ins�Ction of the electrical work at
Range Fire No. Co ' - ' ' —
Pleage Provide T ) rre umbers
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Address
Co c r Uce� N�mbqy Master Electrician or P
( At n �°i/ Licertse Number
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Please ProWde T o 2) Phone Niunbe�s I
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