P - 77028REQUEST FOR ELECTRICAL INSPEC—T�,I.O�N
1����� `�" S � 821 Unrversity Ave � e 3uite S- 28, Sa�D� Min �� 104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW ❑ REMODEL O ADDITION EPAIR Describe -using the back of the white copy 'rf necessary - the work covered by this request:
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ENE L FEES utdoor Lightiny Standard �$1 ,„
401 to
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
Trafic Signal Standard
Supplemental Fee @ E
Transfortners uo to 10
� Transfortner I Power Supply for Signs I Outline Lighting @$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspec6on Trips Each Dwelling Unit @$80
Addi6onal Insp?cGon Trips @ $20
Inves6aative Fee
(minimum total fee is $20) .� `f , Q
iH15 AREA Fdi INSPECTpt USE MY
I hereby cer6y tl�at I inspec0ed the electrical installation described herein on the dates sta0ed:
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i� Ins tion $30 r Hour `"""`°,^'"^""`°
pecial Inspection @ $.31 per Mile
� INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 M
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1 7 4 3 7 8 8 0
Request Date: Rough�n Inspection Required? ❑ Yes No Irepedion Other Then Rough-In: ❑Ready Now Will Call
� L�— � You must call the inspector when ready! Date Ready:
I certi(y that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspectlon of ihe electrical work at::
Job Site Address (Street, Box, or Route No.) City Zip Cade
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�any Name
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: aitractor, Company or Owner Performir
.cH�i'r/�i49� �
ure (Contractor, Company or Owner Perl
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Master EIecNGan or Power Limitetl Technician
License Number
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(s)
�.�"37- �7.3 /
EB-00001A-14 8.1.2002