P - 78926REQUEST FOR ELECTRICAL INSPECTION
�� 6 q. �� 6 9 6 � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Sairrt Paul, Minnesota 55104
� ��j'� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
❑ NEW REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoor Li htin Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Am re $25 Supolemental Fee (� $20
ALARM; COMMUNICATION, REMOTE CONTROt
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus $.50
ADDITIONS TO THE GENERAL
3 to 12 Units @$50 Pet Unit ,
Each Addifion� Unit � E25
INSTALLATit
III�� IIIII I���I II�I� I�III �I�II I�III IIIII �� I�
16476962
�_ Transformer / Power SuDD�Y for Sans / Outline Liqhting �$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
CirouiLs and Two Inspection Trips Each Dwelling Unit � EBO
Addition� Inspection Trips $20
� Investioa6ve Fee
TOTAL FEE ,SU
(minimum total fee is $20) p�a
T H5 MEA FOR INSPECTpi USE OKV
I hereby cerU(y that I inspecBed the electrical installa6on desdibed herein on the dates sfa6ed:
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Request Date: Rough-in InsPection Required? ❑ Yes
��spection Other Than RougMn: �Ready Naw�plll Call
� a� ' b You must call fhe inspecta wh� ready! Date Ready.
I cefify ihat I am ihe �ICENSED CONTRACTOR ❑COA�PANY ❑ OWNER and hereby request inspection of the elecUical work at:
Job Site Address (Street Box, w Route Pb.) ZiD Code
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ELECTRICT' COPV
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ro(2) Phane I�mber(s) Induding Ar@a Co�
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Master dectrician a Power Limited Technician
License Number
(s)
EB�OW01M74 � 8.1. ZOq2