P - 78200REQUEST FOR ELECTRICAL INSPECTION
1�� p/.I ��/� Z� Minnesota Board of Electricity -
o��+ �-t 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-08Q0 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
❑ NEW ❑ REMODEL ❑ ADDITION REeAIR Describe -using�fielback of the white copy if necessary - the work covered by this request:
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50 �
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Tra(fic Signal Standard @ E5
Supplemental Fee @ $20
Transformers up to 10 KVA (c
Transformers over 10 KVA r
Includes the Service andlor Power Supply up to 500 Amperes, All
CircuiGs and Two Inspection Trips Each Dwelling Unit @$80
( TOTAL FE j I � �
minimum total fee is $20
THIS ARfA FOR INSPECiq2 USE pJIY
I hereby cer6y thffi I inspected the electrical installa6on described herein on the dates stated:
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Requ t Dat : Rough-in Inspection Required? ❑ Y Inspedion Other Than R gh-In: d ❑ Will Call
You must call the inspector when ready! Date Ready: �
I certify that I am the • LICENSED CONTRACTOR �COMPANY C OWNER and hereby 'uest inspectlon of the elecUical work at:
Job Site dress (Street, Box, or Rout No.) / Ci Zi Code
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BOARD OF ELECTRICITY COPY
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License Number
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EB-00001A-14 8.1.2002