P - 78036C ❑ REQUEST FOR ELECTRICAL INSPECTION
1��i ��- 7 3 4 1. Minnesota Board of Electricily
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-0BOOTfY/MRS1-800�27-3529 www.electricity.state.mn.us
❑ NEW ❑ ODEL ❑ AD TION ❑ REPAIR Descri using the ack of the white copy rf necessary - the work covered by this request:
6 NERAL FEES Outdoor Li htin Standard $1
SERVICES I POWER SUPPLIES TraRc S' nal Standard $5
0 to 400 Ampere @$25 Sunolemental Fee Ca1820
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or s 5.50
ADDITIONS TO THE GENERAL FEES
2 Units � S50 Per Unit
Additional Unit @ 525
OTHER ADDITIONAL FEES
n Retrofit $.25 er Fixture
x Pivot Irtigation Boom � yl0 ,
factured Home Paric Lots �1 E25
ational Vehicle Park Sites � S5
�a
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, Ail
Circuits and Two Inspection Trips Each Dwelling Unit @ E80
TOTAL FEE
(minimum total fee is $20) D ' �
iHIS AREA FOR WSPECTOft USE 011r
I hereby ceNy Mat I inspected the elecbical installation described herein on tlie d�s sta0ed:
i-+l/- iz ., c • �: 3
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ins � s►�w��UP1 MAT 13t VKUERED DISGONNEGTED IF NOT COMPLETED WITHIN 12 MONTH�
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15487341 �
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I certify that I am ttie
Job site nedress (Sire
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Rcwghin Inspection Required? ❑ Yes ❑ No Inspecfion Other Than Rough-In: y Now � WNI Call
You must call the inspecla when ready! Date Ready:
NSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of 1he electrical work at:
te No.) ` i Gry . . / ZP Code ,/ .
G��o,��
ride Two (2) Phone Numb�(s
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mas[er r�ecmpan or
License Number �
.�r��r �.17�3'�7 ���
�� � BOARD OF EIECTRICIT' COPY EB-OOOOfA-14 8.1. 2002