P - 78238/� REQUEST FOR ELECTRICAL INSPECTION
�,: � 4 6 2��F O O � Minnesota Board of ElecVicity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electricify.state.mn.us
❑ NE �REMODEL ADDITION ❑ REPAIR Describe -using the back of the white copy 'rf necessary - the work covered by this request:
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GENERAL FEES �tdoor Liahtina Standard � i1
to 800
ve 800
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus � 5.50
MULTIFAMILY DV
3 to 12 Units
Special Inspec6on � $.31 per Mile
5 INSTALLATION MAY BE 1
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�I�I �� I�
Traffic Signal Standard
Supplemental Fee @ $
Transformers uo to 10 I
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspecfion Trips Each Dwelling Unit � 580
Additional Insoection Tnos � S20
TOTAL FEE I
(minimum tofal fee is $20) y� � �
iHlS AREA Fp21N5PECip21/5E OPiY
I hereby certiy that I inspected the electrical insWlation described herein on the da0es staled:
D DISCONNECTED IF
12 M
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14624001 �(p�f�
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Request Date: Rough-in Inspection Required? '❑ Yes Inspection Other Than Rough-In: ❑Ready Now � V1r11 Call
� VC�1 �/� You must call the inspector when ready! Date Ready
I certi(y that I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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