P - 79004REQUEST FOR ELECTRICAL INSPECTION
1�� ���� 7 g � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TlY/MRS 1-800-627-3529 www.electriciry.state.mn.us
NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
�iLfr�� !�/j� /{Jr^"' /T�Ii�IZ� �
S / POWER
400 Amcere
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS Of LESS THAN 50VOLTS
3 to 12 Units @
Each Addi6onal
Center
;cial Inspection $30 per Hour "� � �
;cial Inspection $.31 per Mile
WSTALLATION MAY BE ORDE
Outdoor Li h6n Standard $1
_ Trafic Siqnal Standard @ $5
Transformers u to 10 KVA a 510
Transformers over 10 KVA $ 20
Transformer / Power Suppdy for Siqns I Outline Liph6nq_ @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dweliing Unit @$80
TOTAL FE, I � h / �J
(minimum total fee is $20 v
THIS NREA Fqi INSPECiOR USE OPLY
I hereby certiy that I inspected the electrical installa6on described herein on the dates sfaMd:
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1610679L �✓
I certity fiat I am the
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Rough-in InSpecGon Required? ❑ Yes No Inspection Other Than Rough-In• y Now p VWI Call
You must call the inspector when ready! Date Ready:
NSED CONTRACTOR ❑COMPANY ❑ OWNER and,hereby request inspection of 1he electrical work at:
IN57RUCTION3 ON
BOARD OF ELECTRICfTV CAPY
EB-0OOO1M14 8.1.2002