P - 78201REQUEST FOR ELECTRICAL INSPECTION
1�� V�� - 9 5 5❑1 Minnesota Board of Electriaty
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TlY/MRS 1-800�27-3529 www.electriciry.state.mn.us
❑ ADDITIO \❑ REPAIR Describe -using the b� of the white copy if necessary - the work covered by this request:
/POWER
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
TO THE
3 to 12 Units �$50 Per Unit
Each Addition� Unit @ $25
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irtiaation Boom � 54C
Su �lemental Fee $20
Transfortners u to 10 KVA $10
Transfortners over 10 KVA S 20
Transfortner I Power Su t tor Si ns I OuBine Li htin E5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unil @$80
Fee
70TAL FEE I � -J
(minimum total fee is $20) ,
iH15 MEA FOR INSPECTpi USE OKY �
I hereby ceitify thffi I inspected the ekctric� insfalW6on despibed herein on the dates sta0ed:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT CON
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PLETED WITHIN 12 MONTHS , J
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Request ate: Rough�n Inspection Required? Yes ❑ No �ns
pection Other Than Rough-In: ❑Ready Now Wfll Call
� �a You must call the inspector when ready! Date Ready:
I rtify tha am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elechical work aY.: