P - 78134REQUEST FOR ELECTRICAL INSPECTION
1; 5 3 0� J 0 0 � Minnesota Board of Electricity
1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.sta[e.mn.us
, NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
GENERAL FEES Outdoor Li htin Standard $1
Srjj2VICES I POWER SUPPLIES , Tratfic Siunal Standard Ca? $5
2M, COMMUNICATION, REMOTE CONTROL, SIGNALING
:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENER4L FEES
iIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Ligh6ng Retrofit @ $.25 per Fixture
Center Pivot Irriaation Boom � S40
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Tnps Each Dwelling Unit @$80
TOTAL FEE I('(�� s v�
(minimum total fee is $20) � •� ,
iH15 AREA FOR INSPECiIXt 115E WlV
I hereby cer6fy that I inspected cal insfallation described herein on the dates stated:
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� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS __Y_ T
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R te: Rough-in Inspection Required? es ❑ No Inspec[ion Other Than Rough-In: ❑Ready Now II Call
DYou must call the inspecta when ready Date Ready:
I ce that I the ICENSED CONTRACTOR 0 COMPANY � OWNER and hereby request inspection of the elecirical work at::
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EB•00001A-14 8.1.2002