P - 78048REQUEST FOR ELECTRICAL INSPECTION
1� J�F �- 6 0 9� Minnesofa Board of Electricity
1821 University Avenue Suite S-128, Saint Patd, Minnesota 55104
(651)642-080011Y/MRS 1-800�27-3529 www.electricity.state.mn.ur
"❑ NEW MODEL ❑ ADDITION ❑ REPAIR Describe -using the bxk oi the white copy if necessazy - the work covered by this request
!�[,� C �CtUSIJ/1 � S/- 7% 7- �%��S
SERVICES / POWER SUPPLIES
0 to 400 Am ere S25
401 to 800 Am ere a50
Above 800 Am re $75
CIRCUITS I FEEDERS
0 to 200 Amcere an. $5
Above 200 Ampere p$10
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device w Appaatus @$.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units �$50 Per Unit
E�h Additional Unit @ $25
OTHER ADDITIONAL FEES
Li htin Retrofit S•25 er Fi�ure
Center Pivot Irti ation Boom S40
Manufactured Home Paric Lots E2
Recreationai Vehicle P�k Sites
arate Bondin Ins tion E20
S ial Ins 'on $30 r Fbur
Spea� Inspection � E.31 per Mtle
to 10
:r 10
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Grouits and Two Inspection Trips Exh Dwelling Unit @ S80
Fee
TOTALFEE �
(minimum total fee is $20) �
THISARFAFORINSPECT EONLY
I hereby c;er0ry thffi I inspec6ed the ekctrical instatlaNOn described I�erein on Me dates stahed:
ORDERED DISCONNECTED IF
IIIIIIII�IIIIIIIII�III�IIIIIII�IIIII��I�
15446�99
� ��`l
��� �
�i �
�Z�'(� a����
Request Date: Rough�n Inspection Required? ❑ Yes No InspeGion Other Than RougMn: ❑Ready NoMr�WNI Call
� S-�3 You must call the inspector when readyl Date Ready:
I cerMy that I am the �ICENSED CONTRACTat �CONWANY ❑ OWNER and hereby request �spection of tlie electricai work at:
12
..� .............�,•••�•••.••••••�......,..,.. eow�oF�crwcmcorr Fsa000�ku a�.�ooz