P - 78210REQUEST FOR ELECTRICAL INSPECTION
.L � 5 6 3- 9 5 2� Minnesota Board of ElecVicity
1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
❑ NEW REMODEL ❑ ADDITION 0 REPAIR DescYibe -using the back M the white copy'rf necessary - the work covered by this request:
2M, COMMUNICATION, REMOTE CONTROL,
;UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus .$.50
ADDITIONS TO THE GENERAL F
fIFAMILY DWELLINGS (PER UNi�
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Ligh6ng Retrofit @ $25 per Fixture
Center Pivot imaation Boom � S40
Outdoor
Trarisfortners u l010 KVA $10
Transformers over 10 KVA �$ 20
Transformer I Power SuDdY for Sipns I OuUine Lightinq $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
Reins tion Fce $20
TOTALFEE /�
(minimum total fee is $20) �v � S�
TNIS AREA FOR INSPECiOR USE ONLY
I hereby cer6y that I inspected Me electrical insGlla6on described herein on the dales stated:
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I certify that I am the
Jab Site Address (Streel
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Section Townshi{
OwnerlOccupant Name
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Fower s�pp fer
ConVactor / Company N
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Maiiing Address (Contrai
Auth ' �' na (C.�
iNS�x TI S ON BACK I
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Rough�n Inspection Required? es ❑ No Inspeclion Other Than Rough-In: ❑Ready Now Will Call
You must call the inspector when ready! Date Ready:
;ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and heieby request inspection of the electrical work at:
a F2oute No.) —.. . . r . ., ZiP Code
I ��1i1 fi �c s i
�� Please I
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Power Supplier Address
Contrador License Nurr
(cGf-riG
�y or Owner Performing Insta latlon)
-�en�.�. , �re -I- t
mpany or Owner Periortmng Ins lation)
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� 90ARD OF ELECTRICITV COPV
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master tiecmuan a
License Number �,
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EB-0OOOtA-14 8.1.2002