P - 79291REQUEST FOR ELECTRICAL INSPECTION
� r 1 Y� �- 5 4 2 0 Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
' , (651)642-0800TTYIMRSI-800�27-3529 www.electricity.state.mn.us
❑ REMODEL � ADDITION ❑ REPAIR Descrihe -using the back of the white copy if necessary - the work covered by this request:
?tCEL E�1Ef?GY SA'�lER'S SWIT�H
GENERAL FEES Outdoor Liohtinn S!andard (� $1
SERVICES / POWER
ALARM, COMMUNICA710N, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Traffic Signal Standard
Suo�lemental Fee na $
Includes the Service andior Power Suppiy up to 500 Amperes, All
CircuiLs and Two Inspection 7rips Each Dwelling Unit @$80
Fee
Fee
$50 Per Unit (minimum totai fee is $20) � ���.�v0
Unitep $25 �rusu�EnFOrsws�croausEOrar
1 hereby cer6ry thal I inspected tlie electrical install�on descnbed herein on the dates sfa�d:
OTHER ADDITIONAL FEES � Lc �— Gr � J 3
(nl S �5 nar Fivtura
I�I i! Iil fl � II III L111I � ill II 8I N N( II 111 I�II
177354�4
2-
)NNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Request Date: Rough-in Inspection Required? C] Y� L7jIYo Inspedion Other Than Rough-In: LJFQtady Now LJ VIRII Call
��df[� You must call the inspector when ready! Date Ready:
I certify that i am the C�ICENSED CONTRACTOR � COMPANY ❑ OWNER and hereby request inspection of the electrical work at: