P - 78455(� REQUEST FOR ELECTRICAL INSPECTION �
1� 5-�16 �� J� � 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 ❑ REMODEL ADDITION REPAIR Descri using the back of the white copy if necessary - the w covered by this request:
1 ..P�, � /��I� _ � ,
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Per Unit
Each Additional Unit � $25
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IIII �I III �) III �I III (I II) �I (�� II III II II) u� IMI
1 5 1 6 7 9 8 4
Traffic Si nal Standard $5
Su lemental Fee $20
Transfortners u to 10 KVA @$10
Transformers over 10 KVA $ 20
Transformer / Power Su for Si ns I Outline Li h6n $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Include.s the Service andlor Power Supply up to 500 Amperes, All
Cirouits and Two Inspection Trips Each Dwelling Unit �$80
TOTAL FEE I ,�
(minimum total fee is $20) ad
TMIS RREA Fqi MSPECTOR USE 011Y
I he2by cer0y Mat I inspected the electrical instaq�on described herein on the da�s s�ed:
COMPLETED WITHIN 12
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/O t� I� I Rough-in Inspectiion Required? ❑ Yes ❑ No Inspection Other Then IZougMn: Ready I�w O Wfll Call
You must call the inspecta when ready! Date Ready:
I certify tliat I am the ICENSED CONTRACTOR ❑ CON�ANY ❑ OWNER and hereby request inspection of tlie electrical work at:
Job ' Address ( Box. a Route No.� Zip Code
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Sedion Township nge Fire No. CouMy C/V "'`'��Q�
OvmedOaupa me Please Provide Two (2) Phone Number(s) Induding Area Code
�Y1/In�i �m i� �. ( . �'7/-3/3 4 )
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BOARD OF ELECTRICRV COPY
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EB-0OOO7M14 8.7.2002