P - 78458REQUEST FOR ELECTRICAL INSPECTION
1�4 9 2���� � Minnesota Board of Electricity ` -
7821 University Avenue Suite S-128, Sairrt Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW O REMODEL ❑ ADDITION EPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
Sia ( %r�r a�s Ga�''Q e i r�
GENERAL F S Outdoor Li htin Stan ard $1
SERVICES I POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Am re $25 Su lemental Fee $20
401 to 800 Amcere � S50 Trarisfortners uo to 10 KVA �$10
CIRCUITS OF LESS THAN 50 VOLTS
MULTIFAMILY DWELLINGS PEI
3l012 Units @ $50 Per UnH
Each Additional Unit � $25
Mile
IIII II II� II I�I II I�I II III II III �) III II III �� I�.
1 4 9 2 7 3? Q
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$60
Additional Inspection Trips . $20
Investiaative Fee
TOTALFEE r
(minimum total fee is $20) �Ot,� o
iN15 NiFA Fdt 115PECTOR USE QlY
I hereby cer6fy that I inspecled Ihe ekttrital i�alWdon described I�sein on the da4e5 s1�ed:
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CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elecUical work at: