P - 77748REQUEST FOR ELECTRICAL INSPECTION
1� 7 2 J�� 5 2 � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� 3q^ (651)642-(jjS00TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
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❑ NEW REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of fhe white copy 'rf necessary - the work covered by Nis request:
13010 a�5 Co 5(-'�'11- 1$S
GENERAL FEES Outdow Li hGn Standard $1
SERVICES I POWER SUPPLIES Traffic Si nal Standard ES
0 to 400 Am re E25 Su emental Fee $20
401 to 800 Am re $50 Transfortners u to 10 KVA $10
Above 800 Am re $75 Transformers over 10 KVA $ 20
CIRCUITS I FEEDERS Transformer I Power Su I for Si ns / Outline Li htin $5
0 to 200 Am re $5 r NE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspecfion Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins tion Tri $20
Each Svstem Device or An�aratus (� 5.50 Invacfinafiva Faa
I IYHMILT UWtLLINIiJ F'tK UNI I TOTAL FEE I �
3 to 12 Units @ E50 Per Unit (minimum total fee is $20) p��
Each Additional Unit �$25 rws ue� Foa ira�croa usE ora.
I hereby certi(y tha11 inspected the electrical insfalla6on described herein on the dates sfaled:
OTHER ADDITIONAL FEES ^ "� / �
Liahtina Retrofit Cd 5.25 cer Fixture ���� ���./ /�
Hour
Mile
i ma ��►�va i wn inAT est uKUtKtu u15GONNEGTED IF NOT GOMPLETED WITHIN 12 MONTHS _ I
I II� I
III II,,, IIIII illll II�II IIIII IIIII IIII! p�l 11�
1729552'
Requesc uaie: Rough-in Inspection Required? ❑ Yes �NO �nspection pther Than Rough-In: ❑Ready Now Will Call
,— a�- QS You must call the inspecta when ready! Date Ready:
I certify that I am the �210ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at::