P - 78594REQUEST FOR ELECTRICAL INSPECTION
1����.— g 2 2� Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(/�.��� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW EMODEL DD yTION ❑ R PAIR Describe -using the back of tt�e white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoor Li htin Standard $1
SERVICES I POWER SUPPLIES . TraRc Si nal Standard E5
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units
Each Additio
Boom
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ONE & TWO FAMILY DWELLIN�S, tn�n Urvi i
Includes ihe Service andlw Power Supply up to 500 Amperes, All
Circuits and Two Inspec6on Trips Each Dwelling Unit �$80
Additional Inspecdon Trips $20
Investiaative Fee
TOTAL FEE � !J
(minimum total fee is $20) � ����
iH6 NiFA fpi 1ISPECTIXt USE 011Y
I hereby cerAfy th� I inspec�d the � insMatlaOai destxibed haein on tlie daks sf�ed:
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Request Date: Rough-in Inspedion Required? ❑ Yes No Inspection Other Than Rough-In: �Ready Now I Cell
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I certify tliat I am 1h��'CICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Address Street BoX a Roule No.) �Y ��8
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Ham Cake, MN 55.904
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License Number
ONBACKOFYELLOWC . BOARD ELECTRICfTYCOPV EB-0OOO1Mt4 8.1.2002