P - 78255REQUEST FOR ELECTRICAL INSPECTION
1� 4 3 6- 413 �7 Minnesota Board of Electricily
f 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
`� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
NEW ❑ REMODEL 0 ADDITION ❑ REPAIR �scribe -ysing the back of the white copy if neFessary - the work covered by this request:
iM, COMMUNICATION, REMOTE CONTROL, SIGNALING
UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device w Apparatus @ 5.50
ADDITIONS TO THE GENERAL FEES
fIFAMILY DWELLINGS PER UNIT
3 to 12 Unifs @$50 Per Unit
Each Addi6onal Unit @ $25
OTHER ADDITIONAL FEES
Lighting Rehofit @ 5.25 per Fixture
Center Pivot Irrioation Boom � E40 .�. .. ..
TraRc Signal Standard
Suo�lemeM� Fee 0 S
Includes the Service andlor Power Supply up to 500 Amperes, All
Cirouits and Two Inspection Trips Each Dwelling Unit @ 580
( TOTAL FE j I �, S
minimum total fee is $20
iM15 ARFA FOR INSPECTIX2 USE pLY
I hereby certify tliffi I inspecfed the ek�c6ical insfall�on described herein on the dates stated:
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�uest Date: Rough-in Inspection Required? Yes ❑ No Inspedion Oth� Than Rough-In: ❑Ready N II Call
�' `� �� You must catl ttie inspecla wh ready! Date Ready.
I certiry that I am the�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Address (SVeet B u, or Route No.) City ,►� Zip Cod
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EB-0OOO1M71 8.1. 2002