P - 782311 � � � � � � � ^ � REQUEST FOR ELECTRICAL INSPECTION
�f Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-0BOOIIY/MRS 1-800-627-3529 www.electncity.state.mn.us
❑ NEW REMODEL 0 ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
I SERVICES / POWER SUPPLIES
CIRCUITS OF LESS THAN 50 VOLTS
Traffic Signal Standard
Suoolemental Fee (�a $
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
fIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units @$50 Per Unit (minimum total fee is $20) �, S
E2Ch Addi60nel Unit �$25 *��s u� Fw irsaECron usE «ar
I hereby ceray that I inspecfed the electrical installation described herein on ihe dates staled:
OTHER ADDITIONAL FEES � /r ` � � �
h6n Rehofit $.25 er Fixtu�re�/� �
Center Pivot I' ation Boom .prv ROU(311 M bs �,Te �
Manufactured Home Park Lots $25 v' ��� �
Recreational Vehicle Park Sites $5 F'"""�s�cr'°" ' °"rE
Se arate Bondin Ins tion 320 — c'
$ i211�5 60n a30 �FbU� e�waeor�a„na� oare
S ial Ins tion $.3t r Mile
S INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
I� IIIII IIIII IIIII III�I IIIII IIIII IIIII �� I�
14973846
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Kequest uat : Rough�n Inspection Required? 7O Ves ❑ No Inspecfion Other Than RaigMn: ❑Ready Now �,YNII Call
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/ l�� You must cali the inspector when ready! /O�� Date Ready:
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I certi(y that I am ihe � LICENSED CONTRACTOR ❑ COMPANY 0 OWNER and hereby request inspection of the elechical work at:
eouto oF �cTwcm coar
E&00001M14 8.1.2002