P - 78377REQUEST FOR ELECTRICAL INSPECTION
1� Minnesota Board of Electricity :- s
.� 16 �� O� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
' (651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us "'"�
0 NEW ❑ REMODEL ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
GENERALFEES
0 to 400
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aratus $.50
ADDITIONS TO THE GENERAL FEES
2 Units @ $50 Per Unit
Addifionai Unit � $25
ALLATION MAY BE ORDERED I
Outdoor Li h6n Standard $1
Trafic Si nal Standard $5
Su dement� Fee $20
Transformers u l010 KVA $10
Transfortners over 10 KVA $ 20
Transformer / Power Su for Si ns I Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes tt�e Service andlor Power Supply up to 500 Amperes, All
Circuits and Txro Inspec6on Trips Each Dweliing Unit �$80
TOTAL FEE I
(minimum total fee is $20) �� � D
iH15 MEA FOR INSPECTOR USE plY
I hereby cer6y that I inspected tlie electric� i�tallaUOn described h�n on the d�es st�ed:
2' -
iiiiiiiiiiuiii�i��i�iiiiiiii�iiii��i�i��i� ���
�a��1 161011 ,�a��
�� o-vS a v► 51- y177 �%� �6 �
Request te: Rough-in Inspection Required? Yes ❑ No Inspection Other Than Rough-In: ❑Ready NoYV ❑ Will Call
�`� �� You must call the inspecta when ready! Date Ready:
I ce' that I am the X LICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of the electrical work at: