P - 76404REQUEST FOR ELECTRICAL INSPECTION ,/ -���'°
1� 8�� c� � 5 q, � Minnesota Board of Electricity " �;-
❑ 1821 Univecsity Avenue Suite S-128, Saint Paul, Minnesota 55104 -
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back oithe white copy'rf necessary - ihe work covered by s request:
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` GENER4L FEES Outdoor Li htin Standard $1
SERVICES / POWER SUPPLIES Traffir Cinnal CtanAarri (rT RS
0 to 200 Am ere a$5
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unft
Each Additional Unit (� 825
Home
Transformers up to
Transformers over
ONE d� TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, A�I
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ion Tri s$20
Investi ative Fee
Reins ion Fee $20
TOTALFEE �
(minimum total fee is $20) 1
THISAREFfORINSPECTqiUSEONLV
I hereby certity that I inspeded the el installaGon described herein on ihe dates stated:
ROUGHIN �
2 �� A A
FINPL INSPECTION /� - r�
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Speciallnspection $.31 rMile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rou h-in Ins
�//� � g pection Required? Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now Will Call
You must call the inspector when ready! Date Ready:
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY �OWNER and hereby request inspection of the electrical work ai
Job Sde SVeet Address C�Y
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Oymer P rming InstallaGon) Ple�vide Twa (2) Phone Numbers Including Area Code
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)PY BOARD OF ELECTRICIN COPY EB-OOOOtA-15 8.1. 206, i
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