P - 78426��-----
REQUEST FOR ELECTRICAL INSPECTION
1 � � �.� � 9 � � � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
�� (651)642-08QOTTY/MRS1-800�27-3529www.electricity.state.mn.us
❑ NEW ❑ REMODE � ADDITION PAIR Describe -using the back of the white copy if necessary - the work covered by this request:
/' :i � _ � r ,/1 t
/ICES I
0 to 400
CIRCUITS I FEEDERS
0 to 200 Ampere @ $5
Above 200 Ampere @$10
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus �$.50
ADDITIONS TO THE GENERAL
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
E�h Addi6onal Unit @ $25
Boom
oer Hour
per Mile
MAY BE ORDERED DISi
I�II II III II III (I III �� II� (I III II I�I I� III (� II) I�11
14839237
— rUr+'�.;CA
Outdoor Liahtina Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Cirouits and Two Inspection Trips Each Dwelling Unit �$80
TOTALFEE
(minimum total fee is $20) ��,�
TMIS RREA Fp21N5PECTOR USE pAY
I hereby cer6fy that I inspecled the electricat insfalla6on described h�ein on the dates stated:
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Request Date: Rough-in Inspectlon Required? ❑ Yes ❑ No Inspedion Other Than Rough-In: Ready Now � Will Call
���ol O`,� You must call the inspecta when ready! Date Ready: O
I certify that I am th�I.ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of tlie electricai Mrork at::
INS7RUCTONB ON BACK OF VELLOW COPY BOARD OF ELEC7RICRV COPY EB•00001A•74 �8.1. 2002