P - 78985/� REQUEST FOR ELECTRICAL INSPECTION
1 s�l, 9 7—�� 7 � Minnesota Board of Electricity -
��� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
I/ (,.� "°l' ' (651) 642-08001T`//MRS 1-800-627-3529 www.electriciry.state.mn.us
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❑ NEW ^6yREMODEI ❑ ADDITION ❑ REPAIR Describe -using the b of the w ite copy if necessary - the work covered by this request:
�\ ��--'C� �� ^ �.c.� .i'.� � � � —
GENERAL FEES Outdoor Li h6n Standard $t
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Am re $25 Su lemental Fee $20
401 to 800 Am re $50 Transformers u to 10 KVA $10
Above 800 Am ere $75 Transformers over 10 KVA $ 20
CI CUITS / FEEDERS Transformer / Power Su I for Si ns I Outline Li htin $5
0 to 200 Am re $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $t0 Includes lhe Service and/or Power Supply up to 500 Amperes, All
ALARM. COMMUNICATION. REMOTE CONTROL. SIGNALING Cirooits and Two inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus an $.50
TOTALFEE
(minimum total fee is $20) p?C � SU
THIS MEA FOR IKSPECipR USE ONLV
I hereby certify that I inspected the electrical inst�lation described herein on the da0es stated:
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Hour
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1 4 9 7 9 2 7 2 e���-
3�1398 �sa
• ""`°" `�e. Rough-in Inspection Required? ❑ Yes �
}� ��spection Other Than Rough-In: ❑Rpady Npay yyill Ca11
V� You must call the inspector when ready! Date Read :
Y .
I certify that I am ihe �CICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electripl work at:
Jeh Ri�n adn.�� i ___. e-- — .. _ . .. . .