P - 78484REQUEST FOR ELECTRICAL INSPECTION
1� 5 1 2— 2 4 9 � Minnesota Board of Electricity
`�� /,/ 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
"(��/ (651)642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
❑ NEW 2MODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
l�,r� r'�Ga �.�r� (o S/ ���I i-7u� � ,�,
✓ICES /'POWER
0 to 400 Amcere
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus .$.50
ADDITIONS TO THE GENERAL
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units �$50 Per Unit
Each Additional Unit � S25
Pivot
� Transformers up to 10 KVA @$10
� Transformers over 10 KVA �$ 20
_ Transformer I Power SuDDIy for Sians / OuUine Li�hting $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Cirouits and Two InspecGon Trips Each Dwelling Unit @$80
TOTALFEE
(minimum total fee i� $20)
T�nsu�wRxar��.oa � �
1 hereby cer6ry Mal I i�xpec�0ed the ektitrical i�rstaHa6on desaibed huein an Me dales sta�d:
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IIIII �IIII �I I�I II III II III Ilill IIIII III�I �� I� �
15122492 �� 50
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Request Date: Rough-in Inspeclion Required? ❑ Yes Inspection Oth� Than RougMn: OReady Now I Call
— 3� You musl call the inspecla when ready! Date Ready:
I certity fhat I am the,� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request �spection of the electrical work at:
Job Site Address (Streel Bo�c a Route No.) CitY Zip Cade
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Masrer r�eanaan a
License Number
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EB-00001M11 8.7. 2002