P - 77283�� REL�UESF FOR ELECTRICAL INSPECTION
1� 7 2 9�� U o �`J � Minnesota Board of Electriciry -
I—J 182� University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electriciry.state.mn.us
❑ NEW ❑ REMODEL ❑ ADDITION 0 REPAIR Describe -using the back of t�J9��e copy if necessary - the work covered by this request:
i e'� \ i—n �1 �f\ t l l �
�M, COMMUNICATION, REMOTE CONTROL, SIGNALING
:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus �$.50
ADDITIONS TO THE GENERAL FEES
TIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Ligh6ng Retrofit @ $.25 per Fixture
Center Pivot Irrigation Boom @ $4(
ManuFactured Home Park Lots (� $
Recreational Vehicle Park Sites �
Hour
II� IIII� IIlil�ll� �!!�I IIIII Ilill ��III a� ��II
17298605
TraFfic Signal Standard
Suoolement� Fee � $
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspec6on Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiaative Fee
( TOTAL FE; I � `�—O
minimum total fee is $20 r �
TNIS ARfA FOR INSPECTOR USE 0l1Y
I hereby certily tliat I inspec0ed the electrical install�on described t�n on tlie da6es sfa0ed:
IF NOT
� d'
���� s _z�-:: ���
��e� ough�n Inspection Required? LJ Yes J� hb Inspection Other Than Rough-In: �eady Now ❑ Will Call
Y \
You must call the inspecta when ready! Date Ready:
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of ihe elecfical work at::
eonrto oF e�cnticm coPr
E&OOOOtA-td 8.1.2002