P - 78963REQUEST FOR ELECTRICAL INSPECTION
1— 6 f 6� 4 0 0 � Minnesota Board of Electricity -
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-62 y-��q www.electricity.state.mn.us "~
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❑ NEW O REMODEL ❑ ADDITION �REPAIR Descdbe -using the back of the white cop ' essary - the work covered by this request:
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GENERAL
SERVICES / POWER SUPPLIES
� Above 200 Ampere (�$10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
Lighting Retrofit
Center Pivot Irrii
c
Traffic Signal Standard
Suoolemental Fee C� $
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspec6on Trips Each Dwelling Unit @$80
F'tK UNI I TOTAL FEE �
Unit (minimum total fee is $20) p?4 ---
�2C TItlS MEA Fpi Ml$PEC1p3 USE ONLv
� Fhereby certify Mat I inspecBed the ekctrical insfalla6on described herein on the dates sia0ed:
; ADDITIONAL FEES � ��� ,f ^ � � � � �L
�er Fi�ure �
bm $40 ao,� iN wTe
k Lots $25
k SitCS $5 aaa wTe
;eon S2o ��-- /'t _Z c —G'/
� ( HOUf EN7�RED/�HV�OONEO WTE
1 Mile
i MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
IIIII �IIII II III II I�I IIIII II II� IIIII IIIII �III II�I
1 6 7 6 4 � 0 3
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Request Date: Rpughin Inspection Required? ❑ Yes
Inspection Other Than Rou9h-In. y Now ❑ Wfll Call
9�� � You must call the inspedpr v,qien r�dy� �� R� .
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I certify that I am ihe �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection o{ y�e electrica� work at:
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