P - 78235REQUEST FOR ELECTRICAL INSPECTION
��'} � O-� 14 � Minnesota Board of Electriaty -
- 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
❑ NEW O REMODEL ❑ ADDITION ❑ REPAIR Describe -usin the bxk of the white copy if nec - ffie work covered by this request:
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GENERAL FEES Outdoor Lighting Standard @$1
ALARM,
CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
� Retrofit @ $.25 per
Pivot Irtigation Boom
�ctured Home P�ic Lc
tional Vehicle Park Si
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes tl�e Service andlor Power Supply up to 500 Amperes, All
Circuits and Txro Inspection Trips Each Dwelling Unit �$80
(minimum total fee is $20) I 2,�, �
rins ueFn Faa iravECTOa usE aar
I hereby ceAify that I inspected the electrical installafion described herein on the dates stated:
WITHIN 12
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14908149.
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Request Date: Rough-in Inspection Required? ❑ Yes ❑ No Inspection Other Than Rough-In: ❑Ready Now ❑ Will Call
`� 23� � You must call the inspedor when ready! Date Ready: '�p�23 a3
I oer6fy ttiat I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of tlie elecUical work at:
iNSrnuc-�s oN e�cK oF reu_ow corr BOARD OF ELECTRICITV CAPV ee-a000�a�e e.�. zooz