P - 78130Q/� REQUEST FOR ELECTRICAL INSPECTION
1� 5 9 3��.J �F � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
, (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
1�'NEW ❑ REMODEL 0 ADDITION ❑ REPAIR Describe -using the back of Me white copy if necessary_the work covered by lhis request:
/ POWER
ALARM, COMMUNICATION, REMOTE CONTROI,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device a Apparatus @ E.50
ADDITIONS TO THE GENERAL F
3 to 12 Units @$50 Per
Each Addi6onal Unit � ;
Lighting Retrofit
Center Pivot Irri�
Outdoor
I Trarisformers up to 10 KVA p$10
� Transformers over 10 KVA p E 20
Transiortner I Power Supply for Signs I OuUine Ligh6nq .$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up l0 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$BO
Additional Inspection Trips (al $20
� Investioative Fee
( TOTAL FE j I ���
minimum total fee is $20 �
iH1S ARE� FIXi INSPEGTOq USE p1Y
I hereby cetify tl� I inspecled the ekcbical instaYa6on described herein on the dMes staBed:
;`i,
5 i� Ins tion 5.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS _
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e� Rough-in Inspection Required? ❑ Yes No Inspadion Other Than Rough-In: OReady Nav � WiII Call
/ Q You must call the inspector when ready! Dale R�dy. .
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of tlie electrical work at:
Job Sile Addrass (Street �. a Route No.) CiH Tap Code
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master t�uvivan or
License Number
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