P - 771301 REQUEST FOR ELECTRICAL INSP€CTION
1�•�- ���— 2 6 3 ,J, Minnesota Board of Electricity /� � -
1821 University Avenue Suite S-128, Sain��� so a 55104
\ (651)642-0800TTY/MRS1-800�27-3529 www.electriciry.state.mn.us """�
0 NEW ❑ REMODEL ❑ ADDIT REPAIR Describe -using the bxk of white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoor Liah6nq Standard Ca? $1
I SERVICES I POWER SUPPLIES
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
MULTIFAMILY DWELLINGS PE
3 to 12 Units @$50 Per Unit
Each Addi6onal Unit @ $25
P��oc
t�sac
Park Lots $
Park Sites
s 6on $2
� $30 per Hour
! 5.31 cer Mile
IIII II (II �I III II �I� II I�I II (II II III (I III �� I�
1563263L
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ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
TOTALFEE �7�
(minimum total fee is $20) �, J v
iH15 AREA FOR iNSPECTIXt USE ONLV
I hereby certify tlwt I inspected the electrical instaNa6on described hereia on the dates sfa�ed:
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Request Da Rough�n Inspection Required? � Yes � Inspedion Other Than Rough-In: ❑Ready Now �j'.. Will Call
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� 2�/6 ou must call the inspector when ready! Date Ready:
I certify that I am ihe �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elechical work at::
Job Site Address (�rcet, Box�, °`' te No.) City Zip Cod
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Section Township K�� Ran� Fire No. CouMy �
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�/Ocwpant Name Please Provide Two (2) Pho/ne Number(s) Induding lvea Code
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UCTI�� OF LLOW COPY BOARD OF ELECTRICIT' COPV
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aster Electrician or Power Limited Technician
� License Number� %�-u � � ? 7
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EB-OOOOtA-14 8.1.2002