P - 79144REQUEST FOR ELECTRICAL INSPECTION
1�?? 5�� 6� � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
f T (651)642-0800TTYlMRS1-800-627-3529www.electricitystate.mn.us
�NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
FEES
Tra(fic Si aal Standard , $5
Su lemental Fee $20
Transformers u to 1� KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / OuUine Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unil @$80
AddiGonal Inspection Trips @ $20
Inves6gative Fee
Reinsoection Fee na $20
I IFAMILY UWtLLINGS PtK UNII TOTAL FEE I 46 .
3 to 12 Units @$50 Per Unit (minimum total fee is $20)
EOCh Addi6onal Unit � $25 TwsnaEaFaenuvECiaauseaar
I hereby certify that I inspected the electrical insWlation described herein on the da�es s�d:
OTHER ADDITIONAL FEES � U � c� j �� 3 G�
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�'+YQ'� "�W� Rough-in Inspection Required7 L�Yes ❑ Plo tr�spedio� pther Than Rough-In: �Ready Now j�l V1ryll Call
12-8-04 yq� must call the inspector when ready! Date Ready:
I cerUfy �rat I am the ff� LICENSED CONTRACTOR 0 COMPANY ❑ OWNER and he�eby request inspection af the electdcal work at:
. __"`_"'_�....�......... ttl-I100{JlA-1{ 8.1.2002