P - 78930� REQUEST FOR ELECTRICAL INSPECTION
1� U� - 4 5 9� Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
J (651) 642-0800 T'fY/MRS 1-800-627-3529 www.electriciry.state.mn.us
W MODEL ❑ ADDITION ❑ REPAIR Describe -using the bxk of the white copy if necessary - the work cove�ed by this request:
A . � i .�.'v _ � .c�
GENERAL FEES � I I Outdoor Ligh6ng Stand
SUPPLIES Traific Signal Standard
401to
CIRCUITS I FEEDERS Transformer I Power Su I for Si ns I Outline Li htin $5
0 to 200 Am re $5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am $10 Includes tl�e Service andlor Power Supply up to 500 Amp�es, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Cirouits and Two Inspec6on Trips Exh Dwelling Unit � L80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins tion Tri $20
Fxh Svstam Ilwviro nr Annatatus �$.50 Investiaative Fee
Retrofit
PER UNI T�T� � � � �� �
Unit (minimum total fee is $20 +
,�^5 TMSRREAFORNSPECiOR IXJIY
� I hereby certity Mal I inspected the electrical instaAa6on described hwein on the da�s staled:
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Request Date: Rpugh-in Inspection Required? ❑ Yes Inspedion pther 7}�an RougMln� dy Now � Wfll Call
-� �' � You must call the inspector when ready! Date Ready
I certify that I am the �ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby riequest inspection of the electrical work at::
--••••..... �.�..�..�..��...vrr E&OOOD1M74 B.t.2002 �