P - 78185r
REQUEST FOR ELECTRICAL INSPECTION
\1 �� v"�`� � O � g121 Un'��versity A en� e 3uite S- 28, ul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800 www.electricity.state.mn.us
/' -• " —
❑ NEW ❑ REM ❑ ADDIT N❑ REPAIR Describe -yAng the k ofjthe wh e copy if n essary - the work covered by this request:
FEES
SERVICES / POWER SUPPLIES
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTNER ADDITIONAL FEE£
�gh6ng Rehofit @ $.25 per Fixture
Center Pivot Irtiaation Boom (a� $40
IIII II� IIIII IIIII III�I II��I I�I�I IIIII �� I�I
15864200
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspec6on Trips Each Dwelling Unit @$80
TOTAL FEE I
(minimum total fee is $20) �/� �
iHIS ARFA FOR I�bPECTqi USE OIIY
I hereby certiry fhal I inspected the elecbical insUlla6on described herein on the dates stated:
�- z %- �" `'�
i�-� j3s7
Cfz:�-a ��o �
av s�
��o�� �U
Request Date: Rough-in Inspection Required? ❑ Yes ❑ No Inspection Other Than Rough-In: Ready Now ❑ Wrll Call
� D You must call tne inspeclor when ready! Date Ready:
I certi(y that I am the �LICENSED CONTRACTOR ❑ COMPANY C OWNER and hereby request inspection of ihe electrical work at:
/�
Job Site Address (Street, Box, or �ioute No.) / _ i CiN , e Zio Code ,
CTRt�3' tNC.
`�! r �
nse Number Master Eleclrician or P
.-. . � i License Number./)
� - ���" �S%'.���
INSTRUGTONS CK OF BOARD OF ELECTRICITY COP� EB-Op0p1A-14 8.1. 2002