P - 78593REQUEST FOR ELECTRICAL INSPECTION
1� 4-19 -17 9� Minnesota Board of Electricity -
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
❑ NEW ❑ REMODEL O ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
�J1��1 � �
GENERAL FEES Outdoor Lighting Standard $1
SERVICES I POWER SUPPLIES Tra(fic Sianal SNandard (d $5 �
401 to 800 Amper
Above 800 Amper
,UITS I FEEDERS
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaralus �$.50
I�IIIIIIIII�IIIIIIIIIIIIIIIIIII��� ��I�
1 4 1 9 1 7 9 5
Su lemental Fee $20
Transfortners u to 10 KVA �$10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns I Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, NI
Cirouits and Txro InspecGon Tnps Each Dwelling Unit �$BO
( TOTAL FE; I ��
minimum total fee is $20
THIS AREA FIXt INSPECTIX2 USE 0l1V
��eby certiry that I inspected the electrical instada6on described huein on the dates stated:
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equest Date: Roughan Inspedion Required7 ❑ Yes Inspection Other Than Rough-Irr. ;(�teady Now O Will Call
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You must call the inspector when ready! Date Ready:
i certiiy ihat I am th , LICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of tlie elechicai work at::