P - 78125REQUEST FOR ELECTRICAL INSPECTION
1�� 1�� o� 1 a 8f21 Unv ersity Avenue Sui�te�S- 28, Saint Paul, Minnesota 55104
(651) 642-0800 7lY/MRS 1-800�27-3529 www.electricity.state.mn.us
NEW ❑ REMODEL O ADDITION ❑ REPAIR Describe -using the back of the white copy 'rf necessary - the work covered by ihis request
�G..+�LV. (GC� �C
GENERALFEES
JICES I POWER SUPPLIES
0 to 400 Amcere � 525 QO
iM, COMMUNICATION, REMOTE CONTROL, SIGNALING
;UITS, CIRCUIT3 OF LESS THAN 50 VOLTS
Each System Device or Apparatus �$.50
ADDITIONS TO THE GENERAL FEES
fIFAMILY DWELLIN�S PER UNI
3 to 12 Units � S50 Per Unit
Each Addi6on� Unit @ $25
OTHER ADDITIONAL FEES
Li htin Retrofit $.25 r Fixlure
Center Pivot Irtiaation Boom � S40
Standard
IFee�$
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, fUl
Cirouits and Two Inspec6on Trips Each Dwelling Unit @$80
TOTALFEE �
(minimum total fee is $20)
rws,�rs� Fat iruvecTOa usE orar
I hereby cer§(y tl�at I inLsp�ect,,e�d the elecbical instaN�on described t�rein an the da0es sta6ed:
-: � I'�t• � /x......�w E �2, f :� �
/n
ROUC�H M! MiE
�� ' �f!
FM14 NSPECTIOIJ OATE
- c-'lS� �y
_ � � rns ins i p►�u� i �c�n MAII 13� VRDERED DISGONNECTED IF NOT COMPLETED WITHIN 12 MONTHS �
�-fr �?o S�
IIflIII�lUllllllllllllllllllllillll���ll� �� �7�-�
15750177 ��S(�
�a�y- �a��zc� ;.
Req Date: Rpugh�n Inspecfion Required? ❑ No Ins
pedion Other Then Rough-In: ❑Ready Now WNI Call
.�l �'� You must call the inspeda when ready! pe� �y;
I certiy that I am the �ZZLICENSED CONTRACTOR ❑COA�ANY ❑ OWNER and hereby request inspection of Ihe electrical work at:
Job Site Address (StreeL Box or Route No.) CitY Tip Cade
a �NN,P��o� �X L 5� `� 3�
SeGion TownsFdp � V � �„� � �MyA � O�
r��� �
PoMrer Supplier
Contractar / Comp�y Nen
� L���
�i:,� naaress �co�aac�c
�k - �:�
.�
�
����
• F o�- �
a
a
Please Provide Two (2) Phone I�mber(s) Indudirg Area I
�'7�3 - zs3 � z?ZL�-
v C.�,.� �.,�.
eawo oF �crnicm cow
Masror tiecv�aen a
License Number
�,l-- �v�,
�,«, �5>
lrr2-3�4- 3o3S
EB-00001M4 8.1.2002