P - 78365[ REQUEST FOR ELECTRICAL INSPECTION
1�`t J�- 5 4 4 9� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
,.. (651) 642-0800 TTY/MRS 1-800�27-3529 www.electriciry.state.mn.us
❑ NEW ODEL ❑ ADDITION ❑ REPAI�2 Descriqe }�sing the back of the wqit� copy if necessary - the work covered by this request:
0 to 400
ALARM, COMMUNICATION, REMOTE CONTROL, SIG'
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or arffius ,$.50
ADDITIONS TO THE GENERAL FEES
TIFAMILY DWELLINGS (PEI
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
FEES
Center Pivot
Outdoor
to 1
ONE & TWO FAMILY DWELUNGS, EACH UNn
Includes ihe Service andlw Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dweliing Unit � S8(1
(minimum total fee is $20) � ' �U
TNISMEA Fqi INSPECTpi USE 0lLY
I hereby cerMy that I inspec6ed the electrical insfallaUOn deuribed herein on the dates st�ed:
S ial Ins 'on $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Request Date: Rough-in Inspection Required? ❑ Yes ❑ No InspeGion Other Than Raigh-�n: �Ready N I Call
You must call the inspector when readyl Date Ready. .
I certity that I am the 0 LICENSED CONTRACTOR ❑ COMPANY � OWNER and hereby request inspection of the electrical waic at:
BACK OF YELLOW COPY
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EB-00001M14 8.1.2002