P - 76143I REQUEST FOR ELECTRICAL INSPECTION �`
I 1�� G�° 4 4� � Minnesota Board of Electricity
1821 Unlversity Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
Desaibe -using the back of the whfte copy if necessery - the work cmvered by this requ�t:
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j GENERAL FE Outdoor Li�htinu Standard (�a $1
Above 800
:URS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device w Apparatus @$.50
ADDRIONS TO THE GENERAL I
TIFAMILY DWELLINGS (PER UNIT1
3 to 12 Units @$50 Per Unit
Each Additional Unit l�D $25
Transtormers over 10 KVA $ 20
Transfortner / Power Su I for Si ns / Outline Li $5
ONE 81W0 FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, M
CircuiGs and Twro Inspection Trips Each D�velling Unit @$80
Additlonal Ins 'on Tri $20
Invasti e Fee
Reins n Fee $20
TOTALFEE �ry
(minimum total fee is $20) ,,�L�, �
TId4 AIgR FOR WSPECIOR Ilg 0lbY
I hereby certlfy tlret I inaped� tlte electrical 6�efa0atlon descrIDed Frere(n on tlre datea s�fed:
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,LLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12
FGR 4FfICE USE ONLY
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"""'' Rough-in Inspecdon Required7 ❑ Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now 0 Wm Catl
� �J � z�° �� You muat call tl�e Inspeaor when readyl Date Ready:
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby r�uest inspectlon of the etectrical work at
Job Site Streef Address Ci1y
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BACK OF YELLOW COPY BOARD OF ELECTRICITV COPY EB-00001A-15 8.1. 2004