P - 783671-5C�1-216 ❑4
❑ NEW EMODEL ❑ ADDITION ❑
GENERALFEES
ERVICES / POWER SUPPLIES , _
0 to 400 Amcere (� $25
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
R Describe -using the back of the white cop if necessary - the work covered by this request:
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ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Anoaratus (a� 5.50
3 to 12 Units
Each Additioi
Center Pivot
Traffic Signal Standard
Supplemental Fee @ $
Transformers uo to 10
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Pc2wer Supply up to 500 Ampe�es, All .e.
Circuits and Two Inspectior�7rips Each Dwelling Unit @$80
(minimum total fee is $20) � �J, �
+iH15 AREA FOR INSPECiOR USE qJIY
I hereby cer6y that I inspected tlje elec6ical installa6on described herein on tlie dates sfated:
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DATE
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IIIII �III II�II IIIII III�I IIIII II I�I IIIII II� I�I
1 5 0 1 2 1 6 4 �,�QJ � ��
I certify Ihat I am ttie
INE7RUC"
.
Rough-in Inspectlon Required? ❑ Yes iJo Inspecfion Other Than Rough-In: ❑Ready Now Will Ca0
You must call fhe inspector wh� ready! Date Ready. .
NSED CONTRACTOR ❑ COMPANY 0 OWNER and hereby request inspection of 1he electricai wak at:
;APV
8.1. 20D2