P - 78050REQUEST FOR ELECTRIC�4L INSPECTION
1� 5 31 � O� p � Minnesota Board of ElecVicity
1821 University Avenue Suite S-128, Sairrt Pa�, Minnesota 55104
�U� (651) 642-0800 TTY/MRS 1-800�27-3529 www.e[ectricity.state.mn.us
❑ NEW E ODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work cove2d by lhis request:
' b'c�uer�e 13��1� �6 3 —�0 33 --9��lS�
Traffic Sinnal Standard
401 to 800
Above 800
,UITS I FEE
� Above 200 Am re $10 ' ( inciudes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Tvro Inspection Trips Each Dwelling Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Addi6onal Ins tion Tn $20
Each Svstem Device or Auoaratus (� $.50 Investiaative Fee
.LINGS PER UNI TOTAL FEE m
S50 Per Unit (minimum total fee is $20) �"`
Unit�$25 .Hisnr�fw�cra+ e«ar
I hereby cerdty that I inspected the electrical insfallaGon described herein on tlie dales sfafed:
OTHER ADDITIONAL FEES �`� _/ G� R z�•3
Mile
IIII II III II III (� III �I II� II III II I� II �I �� I�
1531�980
�l/�G
,�,�o�-��?o �o
Requesl Date: Rough�n Inspeqion Required? ❑ Ves Inspedion Otlwx Than RougMn: ❑Ready Vvll Call
li -(f,� Yau must wll the inspector when readyl Date Ready.
I certi(y tt�at I am the �+CICENSED CONTRACTOR ❑ COIu�ANY ❑ OWNER and hereby request inspection of the electricxl work at: