P - 762232 � � � ' � � � � REQUEST FOR ELECTRICAL INSPECTION ,
s r� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
�� (651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
Describe -using the back of the white copy ff necessary - th� work covered by�is request:
Atmve 800
)MMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Apparatus @ $.50
ADDRIONS TO THE GENERAL FEES
ILY DWELLINGS (PER UNI�
! Units a(� $5D Per Unit
Center Pivot
Lots
INSTALWTIOW MAY BE ORDERED C
II�I I�II� �IIII �II� III�� �II�I ��III IIIII �� I�
215783B0
Su pleme�al Fee a $20
Transformers u to 10 KVA @$10
Transformers over 10 KVA @$ 20
Transformer / Power Su i for SI ns i Outline ' htin $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
TOTALFEE �
total fee is $20) o��
ele�iral insiallatlon desamed herein on the dffi� s�ted:
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IOT COMPLETED WITHIN 12 MONTHS ____
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�� Rough-in Inspecdon Requlred9 ❑Yea �o InspecUon OtherThan Rough-In: 0 Ready Now�Y�l CaII
4- �!��� • You must wIl the inspectar when readyl Date Ready:
I certify that I am the`�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job 3ite Street Address Ciry
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Owner/Ocapant Name Please Provide Two (2) Phorre Numbeis Inrdudircg Area Code
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ie Numbeis Including Area Code
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