P - 765511-638-947 0�
❑� 0 REMOD L�O ADDITION 0
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-08Q0 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
� De '-using the back of the white copy if necessary - the work covered by this request:
Outdoor Liohtina Standard � Si
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or ratus $.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
iER ADDITIONAL FEES
25 per Fi�ure
i Boom � 540
Park Lots � E25
Park Sites � SS
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16389470
� Transfortners up to 10 KVA an, $10
_ � Transformers over 10 KVA p$ 20
Transfortner I Power SuDPIy for Signs I OuUine Liqhtinq $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dweiling Unit @$80
Additional InsDection Trips $20
Investiga6ve Fee
Reinsoec6on Fee (d $20
( TOTAL FE; I � Q'=� I
minimum total fee is $20 `'�`��
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I hereby ceAify that I inspected the elec6ical installa6on described herein on the dales sGled:
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2CTED IF NOT COMPLETED WITHIN 12 MONTHS
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nequesc uaro: Rough-in Inspedion Required7 ❑ Yes � No Inspedion Other Than Rough-In: ❑Ready Now Wi11 Call
/�� You must call the inspedor when ready! � Date Ready:
I certify that I am the '�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of tlie electrical woric at:
Job Sile Address (Stree4'B1ox. or Route NoJ /� City Lp Code
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�� Con Lioanse Nwnber� Master Electrician or
� License Number
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