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❑ NEW ❑ REMODEL ❑ ADDITIQ
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GENERAL
SERVICES / POWER SUPPLIES
0 to 400 Amcere ld S25
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of ElecVicity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
2 Describe -using the back of the white copy if necess the work vered by this request:
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Transformers u l010 KVA a10
Transformers over 10 KVA @$ 20
Transfortner / Power Supply for Sipns I Outline Lightinq .$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Fee
Fee
3 to 12 Units @$50 Per Unit (minimum total fee is $20) ����% �,� v
E2ChAdditi0f121U�if@$25 Tws�aEnFOrsi�cr usEaar
I hereby ceAHy that I inspected the electric� installa6on described herein on the dates stated:
OTHER ADDITIONAL FEES �v fa -� S�`%• °'�
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� THIS
n Boom $4(
Park Lots i
Park Sites '
� tion $2
! 830 cer Hour
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I certify that I
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MPLETED WITHIN 12 MONTHS
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Rough-in Inspection Required? �❑ Yes ❑ No Inspedion Other Than Rough-In: Ready Naw ❑ Will Call
You must call the inspecta when ready! Dale Ready:
�ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electric�zl work at::
or Route No.)� V 1 Qty .�� �, Zip Code
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Rangg Fire No. County ^ � �
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Please Provide Two (2) Phone Number(s) Including Area Code
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BOARD OF ELECTRICITV COPY
nnaster t�ecmcaan or
License Number
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EB-OOOOtA-14 8.1.2002