P - 78027/� REQUEST FOR ELECTRICAL INSPECTION
�., � � � �F - 014 � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 T'fY/MRS 1-800�27-3529 www.electriciry.state.mn.us
❑ NEW REMODEL ❑ ADL�IT�ON �❑ f�PAIR Describe -using the back of the white copy if necess�y - the work covered by this request:
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each SYStem Device or Apparatus �$.50
fIFAMILY DWELLIN
3 to 12 Units @ $50
Rehofit
Mile
Outdoor Ligh6ng Standard
Trafiic Sianal Standard �
0
_ 1 Transfortner I Power Supply fa Signs I Outline Lighfinq @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Suppty up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investigffiive Fee
ReinsDection Fce (a� E20
(minimum total fee is $20) � '"'r(��
� TM5 MEA FIXi �NSPE�,OR �SE «Y.
I hereby cer6ly that 1 inspecOed the alectrical installation described herein on the d�es stated:
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Request Date: Rough�n Inspection Required? Yes ❑ No Inspection Other Than F2ough-In: ❑Ready Now ❑ Will Call
' a— �-- O You must call the inspector when ready! Date Ready:
I certity that I am the �,UCENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of the electripl work at::