P - 79126[� (� REQUEST FOR ELECTRIC L IN PECTION
1� 7 0�"� J� 7 Minnesota Board of Electricity
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
��'ciX� J� (651) 642-0600 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW , EMODEL ❑ ADDITION O REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or atus $.50
ADDITIQNS 70 THE GENEf2AL FEES
Traffic Si nal Standard $5
Su lemental Fee $20
Transfortners u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns I OuUine Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH t1N1T
Includes the Senice and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspec6on Trips Each Dwelling Unit @$80
Fee
fIFAMILY DWELLINGS PER UNI (�,,p� �,�,�''TOTAL FEE I -� "'�
3 to 12 Units @$50 Per Unit 1' \`�� inlmum tot21 f22 IS $20) �� _�
E2Ch Addi50f121 Unif � $25 '"�s"�"F°`i'"s�'°RUSE°"�v
I hereby cerfiry thal I inspec0ed the electrical instaNamo� described herein on the da�s st�ed:
^ OTHER ADDITIONAL FEES ,�; v � � � -�_��
I IIII II Ifl II III II III II III II II( II III II �I �� I�
17038589
Request Date: Rough-in Inspection Required? ❑ Yes
\ �� y You must call the inspector when readyl
I certify lhat t am ihe ❑ LICENSED CONTRACTOR O COMPAN
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}'No I Inspedion Other Than Rough-In: OReady Now�Wfll Call
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� Date ReadY . �
❑ OWNER and hereby request inspection of the electrical work at:
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