P - 78378REQUEST FOR ELECTRICAL INSPECTION
1� 4 5 8- 5 4 4� Minnesota Board of Electricity
1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
(651) 642-0800 T'fY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
R�'P�► �R ��.c. ne.cA L D 9Mi4G E To SERJ� CE 9�cM�.
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Per Unit
Each Addi6on� Unit � $25
IIIII (IIII IIIII (I�II IIIII II�I II�I) IIIII �� I�I
L4585442
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
Inves6 aGve Fee
Reins tion Fee $20
TOTALFEE
(minimum total fee is $20) e
� THISFREAFORNSPECTORUSEpLY
I hereb�at I inspecte�the electrical instaYalion desaibed htxa'n o� d� d:
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Request Date: Rough-in hispection Required? ❑ Yes Inspedion Other Than Rough-In: �Ready Now Wfll Cail
��• 7�Q �j You must call the inspector when ready! Date Ready:
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I cerMy that I am the ICENSED CONTRACTOR ❑COIu1PANY ❑ OWNER and hereby request inspection of the elecfical wak at:
Jab Site Address (Street, Box, or Route No.) City Lp Code
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Sedion Township Range Fire No. Coun
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Owner/Oaupant Name Please Provide Two (2) Phone Number(s) Induding Area Code
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Power Supplier Power Supplier Address
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�/ I 1 U 1/ Y N 1( 7 1 Y I \/ IJCkJ� V �l !O �( Qumber Master ElectriaaA n�toa 3��
H License Number
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npany or �wner rerrwmi mscanaaon�
. �.���4e� /l/t N �5��30
, Company or Owner Perfortning Insfallation) Phone (s)
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/W COPY BOARD OF ELECTRICITV CAPV EB-00001M14 8.7.20D2