P - 78056REQUEST FOR ELECTRICAL INSPECTION
1��� Z� 0� 6 � Minnesota Board of Electricity
1821 University Avenue Sufte S-128, Saint Paul, Minnesota 55104
. (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
0 NEW •EMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of ihe white copy if necessary - the work cov red by this request:
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GENERAI fEES Outdoor Li h6n Standard $1
SERVICES I POWER SUPPLIES Tralfic Si n� Standard $5
0 to 400 Am re $25 Su ementai Fee $20
401 to 800 Amcere �$50 Transformers up to 10 KVA @$10
CIRCUITS I FEEDERS Tr�sfortner I Power Su I for Si ns / Outline Li htin S5
0 to 200 Am re $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Exh Dweliing Unit @$60
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Addi6onal Ins tion Tri a20
Each S stem Device or aratus $.50 Inves6 ative Fee
ADDITIONS TO THE GENERAL FEES Reins 6on Fee $20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units @$50 Per Unit (minimum total fee is $20) � � �"j�
E2Ch Addi60flel U�if @$25 rms u� Faa iraaECTaa usE «xv
I hereby certiy Mat I inspec�ed the ekctrical instaNa6on described herein on the dales sfated:
OTHER ADDITIONAL FEES
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DATE
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S ial Ins tion $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
I(�II �I III IIIII II II) II III II �II �) (� (I�I �� I�
15120561 ��9�0 ,�j.s'O
Request ate: Rough-in Inspection Required? Yes ❑ No Inspedion Other Than Rough-In: �Ready Now II Call
You musl call the inspector when ready! Date Ready:
I ce' that I tt�e ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electripl work at::
Job Site Address (Street, Box, or Route No.) f � � City�� w' n Zip Code
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Master EleCincian a
License Number
I (7631783-7080 , L2� I
INSTRUCTONS ON BACK OF YELLOW COPY BOARD OF ELECTRICRV COPV EB-0OOO1M14 8.1. 20D2