P - 75760�
1-781-321 3�
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GENERAL
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity o�(,�OS' �I�O fo
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
�- the work covered by this request:
=L Eh1EFiGY SAVEF: ' S SW I TCH
Outdoor Liphtinp Standard na. $1
)MMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
@
Pivot
Fixture
Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
Transformer I Power Supply for Signs I Outline Lightlng @$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Serrice andlor Power Supply up to 500 Amperes, All
Circufts and Two inspection Trips Each Dwelling Unit @$80
Fee
iviw�rtt �
total fee is $20) ��5 a '�
I hereby certify thffi I inspected the elecGical installaation described herein on fhe dat� stat�:
°-�i
Special Inspection @ $.31 per Mile
THIS INSTALLATIOPI MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
I IIB II I{� aE � II I� II I� �I I� II III I I fH II �I I IIII
17813213
� Rou h in Ins ctlon Re wred7 ❑Yes No Ins
��LL� f o`y g= pe q �] pection Other Than Rough-In: [�Ready Now ❑ Wfll Cell
You mus[ call the inspector when readyl Date Ready:
I cer�fy that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
INSTRUCT19N9 Opl BACK OF YELLOW COPY BOARD OF ELECTRICITY COPY EB-00001A-15 8.1. 2004