P - 78696'f� REQUEST FOR ELECTRICAL INSPECTION � �
1-�F O 7� 7 0 8 ,� Minnesota Board of Electricity °- �
� �� niversity Avenue Suite S-128, SaiM Paul, Minnesota 55104
' 6 1 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW ❑ REMODEL 0 ADDITION RE AI , escribe -using the back of the white copy 'rf necessary - the work covered by this request:
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GENERAL FEES Outdoor Lighting Standard @$1 _
ALARM, COMMUNICATION, REMOTE CONTROL, SIGI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aratus ,$.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units
ADDITIONAL
er Fixture
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes fhe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dweliing Unit �$80
�v��r�c rl1
(minimum total fee is $20) �?Q,
THIS MEA Fqi NISPECTOR USE ONLY
I hereby cerdry tl�at I inspected the elecbical instaN�on desaibed I�rein on Me da0es stated:
ciai InspecGon @$.31 per Mile I I
NSTALLATION MAY BE ORDERED DISCONNECTED fF NC
I IIII �I II) II �II II I�I (I III I I�t I) III II III ti III I1���
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Requesl Date: Rou9h�n Inspection Required? ❑ Yes No Inspection Other Than Rough-I : y Now � VWII Call
f? Q You must ca�l the inspeclor when readyt Date Ready: Q
I certify tl�at I am the �ICENSED CONTRACTOR �COMPANY ❑ OWNER and hereby request inspecfion of the electrical work at:
Job Site Address (Street Bw4 a Route No.) Ciry Zip Code
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�er �
:ompany Name
- Lt'�ee �Y JC
�s (Contractor� Company w Owi
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ignawre (conva � com
BACK OF COPV
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r Address
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BOARD OF ELECTRICITY CAPY
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E&0OOO1M74 �8.1.2002