P - 78031REQUEST FOR ELECTRIC�AL, INSPECTION
1— 5 4 4- 5 21 � Minnesota Board of Electriaty ✓1�f ,�Q°�()
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TT7/MRS 1-800�27-3529 www.electricity.state.mn. us
W❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back M the white copy if necessary - the work covered by Mis request:
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GENERAL FEES Outdoor ' htin Standard $1
SERVICES I POWER SUPPLIES ,� s. TraRc Signal Standard �$5 n �
Trdnsformers
0 to 200 Am re SS / ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am e$10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit � S80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins tion Tri $20
Each S stem Device or atus S•� Inves' ative Fee
ADDITIONS TO THE GENERAL F Reins tion Fee E20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE T
3 to 12 Units �,1$50 Per Unit (minimum tot21 fee is $20) � V
Each Addi60n21 Unit @$25 r�s r� Fon naaec.a+use ow�r
I hereby catify tha! 1 inspec0ed the electrical insialla6on described huein on the da�s staled:
OTHER ADDITIONAL FEES
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Request Da1e: Raughin Inspedion Required? ❑ Yes ❑ No Inspedion Other Than Rough-In: ❑Ready Now � VYAI Call
l`--�/ You must call Me inspada when ready! Date Ready.
I certify that I am the ❑ UCENSED CONTRACTOR ❑ COIu�ANY ❑ OWNER and hereby request inspection of the electrical woric at:
Job Site nd�ress (Stree fBax, « Rowe%�°-) l % �� / i_ ��.�, l.. h
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COPV EB-00001M/4 8.7.2002