P - 78984REQUEST FOR ELECTRICAL INSPECTION
1� 4 9 7 9 2 6� Minnesota Board of Electricity �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necess - the work covered by this request:
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GENERAL FEES Outdoor Li htin Standard $1
CFRVI(:FC / P(1WFR CI IPPI IFS Trafic Sianal Standard Cn� $5
� Above 800 Ampere @ $75
CIRCUITS / FEEDERS
0 to 200 Am ere $5 `�� ,..
Above 200 Ampere @$10
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
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THIS INSTALLATION MAY BE �RDERE[
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1 4 9? 9 2 6 4
� Transiormer I Power Supply for Signs / Outline Lgh6ng � 5b
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Cirouits and Two InspecGon Trips Each Dweliing Unit �$80
TOTAL FEE I S�
(minimum total fee is $20) _ � �
F�+ i T eir
I hereby certify thffi 1 inspected n escribed herein on Ihe dales staAed:
;OMPLETED WITHIN 12 MONTHS
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Request Date: Rough-in Inspection Required? ❑ Yes �No tnspedion Other Than Rough-In: OReHdy Now lg'1NNI Call I
�-� .�� Yau must caU the inspacta when readyl Date Ready. _ ^
I cerMy that I am the �CICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of ihe elechical wak at: