P - 78735REQUEST FOR ELECTRICAL INSPECTION
�- 4 2 9���� � Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TT`l�MRS 1-800-627-3529 www•electricity.state.mn.us
❑ NEW ❑ REMnODEL ❑ ADDITION EPAIR Describe -using the back of the white copy if necessary - the work covered�hi� ues�
l�( � i L..+ 1 I%t_ k�Ll �'1 % I`� �'"� I`� "�� 13 r%/�'r �
0 to
�0 Am re $5 "'" °"� �" '������- � P u to 5� Am es, All
200 Am re$10 includes ihe Service andlor Power Su ply p P�
)MMUNICATION, REMOTE CONTROL, SIGNALING Grcuits and Two Inspection Trips Each Dwelling Unit �$�1
CIRCUITS OF LESS THAN 50 VOLTS Additional Ins 6on Tri $2�
AUUI I IVIVJ i v i n� o����rv+� ���.. TOTAL FEE /�/�
fIFAMILY DWELLINGS PER UNI (minimum total fee is S2(1) —1 �`
3 to 72 Uni1S �$5U Per Unit 7�,�,F����ipaus�orar
Each Addition� Unit �$25 I hereby ceNfY tl�t I inspacted the d�4ical i^ShatlaAOn deu"bed �" °^ m° da�s s�:
. �� . .._..��-- .._ _ .. . ... _ _. . . _ _ . �._. - -=
OTHERADDITIONALFEES � — � ` " ' —
�ut --" '„--�..._ �" i ` -�
' htin Retrofit 5.25 Fixture '- wrE �
�M
Center Pivot Irri ation Boom S40 —/ �
Marmfactured Home Park Lofs $25 �TE
F����T� _� 2 -7 �'3
o.....e.,s....�1 \/ohirle Park Sitx � $5 ' . _ � i
I(NI �I III II �II II II� II �II II III II �II �� III I� 11� I�I �
�,4293534.
I certify that I am U►e
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Roughan Inspedion Required? ❑ No Irupedion Other Than Rough-In: �Ready Notiv d'�� �eu
ou must call the inspecta when ready� Date ReedY
� n af the elec6ical work at:
LICENSED CONTRACTOR ❑COMPANY � OWNER ard hereby �equest insPectio
�ARD OF ELECTRICIT`/ COPV
Eg-pppp1M14 8.7.2002