P - 78265REQUEST FOR ELECTRICAL INSPECTION
1,� �F 8 8� 4 6 4` � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TfY/MRS 1-800-627-3529 www.e[ectricity.state.mn.us
❑ NEW ❑ REMODEL ❑ ADDITION � REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoor Li htin Standard $1
SERVICES / POWER SUPPLIES . SA Traffic Siqnal Standard na $5 ' . .,
� Above 200 Ampere @$10
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units (a� $50 Per Unit
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
TOTAL FEE (
(minimum total fee is $20) �� J�
THIS AREA FIXi INSPECTqi USE ONLY
I hereby ce ' that 1 inspected the al installa6on ribed n on the dates sfated:
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S i� Ins tion $.31 Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COIIAPLETED WITHIN 12 MONTHS
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Request Date: Roughin Inspection Required? ❑ Yes No Inspedion Other Than Rough-In: ❑Ready Now Will Call
— _ You must call ihe inspeclar when ready! Dale Ready:
I cerMy tliat I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Ad�ess (Street, Box, or Route No.) Ci1Y Zip Code
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Sedion Township Range Fire No. nty
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ctor / Company Name
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Address (Contractor, Company or
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Signature (Contrap r, Co ai
n7N8 ON BACIFOf�€LLOW GOPY BOARD OF ELECTRICITV COPV
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ise Number Master EJectriaan a Pi
— License Number
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EB-00001A-14 8.1.2002