P - 78401REQUEST FOR ELECTRICAL INSPECTION
1� 4 9 0- 5 6 3� Minnesota Board of Electricity -
r 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
NEW ❑ REMODEL O ADDI�ION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
SERVICES /
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 UNIT
3 to 12 Units @$50 Per Unit
Each AddiGonal Unit @ $25
Center Pivot
Hour
II�II IIIII II II� II I�I �I��) II�II IIIII (IIII �� I�
1 4 9 0 5 6 3 2
Outdoor
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dweliing Unit �$80
Reins 6on Fee $20
TOTAL FEE
(minimum total fee is $20) �0 • S�
THIS AREA Fq21f5PECTOR USE ONLY
I hereby cerGy that I inspected Me electrical installaGon described herein on the da�s sfabed:
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Requesc ue�e: Rough-in Inspection Required? ❑ Yes �Pb InspeGion Other Than Rough-In: eady Now � Wdl Call
��(�— d.3 You must wll the inspecta when ready! Date Ready.
I certiiy that I am the [�LICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspeciion of the elechipl work at:
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Sec�on Township Range Fre No. unty
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Owner/Oaupant Name Please Provide Two (2) Phone Numb�(s) Indudirg /uea Code
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Power SuPPlier Power Supplier Address
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Cantracta / Cam�any Name ' Contractor License Number Master Eleclncian or Limited Technidan
�nJ 1�., �� c�i�l t/ C?� d O Gf Q� License Mrmber
iiling Address (Contractor, Company w Owner Performing Installation)
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BOARD OF ELECTRICITY CAPV ..
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. EB-00001M14 8.1.2002