P - 79021� REQUEST FOR ELECTRICAL INSPECTION
�� 6� 4��� 5 � Minnesota Board of Electricity -
182t University Avenue Suite 5-128, Saint Paul, Minnesota 55104
�/ ,S/� (651) 642-08Q0 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
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❑ NEW ❑ REMODEL ❑ ADDITION REPAIR� �D� cribe -using the bac f the white copy if necessary - e work covered by is request:
%/�sf�i/ ��.'�JOG?'/� G'%-ivz`' /"��.�''/'l/'/G�� d G�� O �G��
GENERAL FEES Outdoor Lighting Standard @$t
� % O to 400 Ai
I I 40110 B00
3 to
)MMUNICATION, REMOTE CONTROL,
CIRCUITS OF LESS THAN 50 VOLTS
Unit @ $25
Transfortners u to 10 KVA $10
Transformers over 10 KVA (d $ 20
Transfortner / Power Supply for Signs / Outline Lighting @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$BO
TOTAL FEE I {/L �' � O
(minimum total fee is $20) �.:J �
Tnrs na�n Foa xacec.a+usE aar
I hereby certiry Mat i inspected the electrical installaNOn described herein on the dates sUted:
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I certify Uiat I m tl�e
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Rough�n Inspection Required7 ❑ Yes ' No Inspedion Other Th� RougMn: �Ready Nav Will Call
You must call the inspector when ready! pe� �y.
NSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at: