P - 80016REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
� 1-396-134 � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -
(651) 642-0800 TTY/MRS 1-800-627-3529
www. electricity, sta te. mn, us
Identify the work covered by this request:
❑NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR xCE� EA�EROY SA�IER�S SW1�GH
to 400 Ai
)i to 800
bove 800
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or aratus �$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI�
3 to 12 Units �$50 Per Unit
Each Additional Unit � �25
� Retrofit � $25 per Fixture
Pivot Irrigation Boom � $4(
�ctured Home Park Lots � $
fional Vehicle Park Sites �
10
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellinp UnR �$80
� Reinspection Fee �
FOfl INSPECTOF USE ONLY
1 hereby certi�y ihat I inspecle
RWGH IN
FINAL INSPECTION ,
TOTAL FEE
total fee is $20)
tlBfBlll Ofl HIB d91B3 F
DATE
FOR OFFlCE USE ONLY
���
I IIII�I III�I II�I �III �I�II ���I �I� �� I� I�� �
* 1 3961 347* °�S�
Reque���2 Rough-in Inspection Required? ❑ Yes l�No Inspection Other Than Rough-in: � Ready Now ❑ Will Call
You must call the inspector when ready! Date Ready:
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY � OWNER and hereby request inspection of the electrical work at:
Job Address I�, eox�b�c .� AVE NE G� Fi�Q�.� �p �e rJ�3
1
Sectlan Township R�p9� � ir�No. County A��A
�/ V �
0°�"�1tENSON ltATHLEEN M vn«,a
Power Su.p Ip 18f ��� Address
7Gi.�L
Electrical Gwltpstpc,/,�qmp�ylv���T'QN Contractor �ic�;p �y�@y, Master License Numher
r�urv i t�t�: i rti�, liA UUtlCS
Mailin9 P.K�1rf,tsS (GopT[actqc„C,pmQa y,Q�pyvpe 1 P�r(p�Qyqp,lp� I tio�� �114
Y�UI� 1 tf�i��il l CMIA�. KUAU Ailil 1 h'
Authoriz ' nature (Cyy�racto ompany ar Owner Perfortning Installation) Phone �� $�,,,�1 i
� ��
EB-00001A-13 7I1/2000 BOARD OF ELECTRICITY COPY INSTRUCTIONS ON BACK OF YELLOW COPY