P - 78142REQUEST FOR ELECTRICAL INSPECTION
1� C�Ij C, _� C, Q� Minnesota Board of ElecVicity -
J�-r .� .� v 1821 University Avenue Suite 5-128, Saird Pa�, Minnesota 55104
' (651) 642-0B00 TTY/MRS 1-800-627-3529 www.electricitystate.mn.us
❑ NEW �MODEL 0 ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the wak covered by this request:
800
B00
I Above 200 Amoere �$10
ALARM, COMMUNICATION, REMOTE CONTROt
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device w Anuaratus �$.50
Unit �
Outdoor
� Transformers up to 10 KVA @$10
� Transformers over 10 KVA � E 20
Transtortner I Power Supply for Signs I Outline Liqhtinp E5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes Me Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @ E80
Additional Inspection Trips @ $20
Investigative Fee
Reinsoection Fce � S20
�v�n�r�c !- . I
(minimum total fee is $20) v S
THIS ME� Fqt NlSPECiOR lISE 0lLY
I hereby cerGfy thffi I inspected �he elettrical insfaNaAOn described herein on tlie da�s sfaBed:
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� e: Rough-in Inspection Required? Yes ❑ No Inspedion OtF�er Than Ragh-In: �Ready Now VWI Call
'O O You must call the inspecta when adyl Date Ready.
I ' that I am the �CENSED CONTRACTOR ❑ COIu�ANY ❑ OWNER and hereby request inspection of the electrical waic at:
Jab Srte Address (Street, , or rcou[e ra.l I Cttv I Tn r�.
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EB-0OOO1M11 8.1. 2002