P - 75751' REQUEST FOR ELECTRI AL INSPECTION
�� � � � � � 41 � Minnesota Board of Electricity �
1821 University Avenue Suite S-128, mt Paul, Minnesota 1 U4
(651) 642-U800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -wsing the badc of the whlte copy if nec�ssary - the wrork covered by this reque.st: A A
CIRCUITS OF LESS THAN 50 VOLTS
ivstem Device or Apoaratus (�a. $.50
INSTALLATION
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18341412
Standard
Tiansiormers wer 10 KVA $ 2(I
Transformer / Power Supply for Signs / Outline Lighbng @$5
ONE & TWO FAMILY D1PIELLINGS, FACH UNR
Includes the Service andlor Power Supply up to 500 Amperas, All
Cirq�fis and Two Inspection Trips Each Dwe@ng Unit (o� $SO
TOTAL FEE
total fee is $201 �Q+
tne etecVical instauailon a�aibea herein on
IF NOT COMPLETED 1t111THIN 12
F6R OFRCE USE ONL'f
'..2 ,�c °�iJ
�' � � Rough-in Inspectfon R�ufred? ❑Yea � Inspectlon OfherThan Rough-In: 0 Ready Now OWIO Cell
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/ You must ca0 tlre inspector when readl Date Ready.
I certify that I am the �ENSED CONTRACTOR ❑ COMPANY � OVNNER arM hereby r�uest inspection of the electricxl work at
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� Company or Owner Qerform
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Fire No. Counry �
Please Pravide Two (2 P' un
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,se Nurnber Mas�r o�ida
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Piease Provide Two (2) Phone Nim
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