P - 78140REQUEST FOR ELECTRICAL INSPECTION
1���� - 3 6 2❑0 Minnesota Board of ElecVicity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
I❑ NEW �REMODEL ❑ ADDITION ❑ REPAIR Des�ribe -using the b�,�csflhe white copy'rf�ecessary - the v�ork c�ered by this request:
GENERALFEES
SERVICES I POWER SUPPLIES
ZM, COMMUNICATION, REMOTE CONTROL, SIGNALING
;UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus � E.50
ADDITIONS TO THE GENERAL FEES
fIFAMILY DWELLINGS PER UNI
3 to 12 Units � S50 Per Unft
Each Additional Unit @ E25
OTHER ADDITIONAL FEES
Lighting Retrofit @ 5.25 per Fixture
Center Pivot Irriaation Boom � f40 � n �. ._
Standard
IFee�S
Transformer / Power Su I for Si ns I Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Inciudes the Service �dlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
Additional Ins tion Tri $20
Inves' ativeFee
Reins tion Fee $2(1
TOTALFEE
(minimum tal fee is $20) Q • ��
TWSAREAFOR p2U5E011Y
I hereby ceNfy tl� I inspected electrical' " n described herein on the dates stated:
Li��1
� i rns ins i ALUo► I wn MAT 13t V1zDERED DISGONNEGTED IF NOT COMPLETED WITHIN 12 MONTHS p�
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��e� � Rough-in Inspection Required7 ❑ Yes Irupedion Other Than Rough-In: ❑Ready Now Will Call
You musl call the inspector when ready! Date Ready.
I certiiy that am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspec6on of the electrical work at::
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�ALLEY HEATING & AIR
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1 Ul /SlO�
Master �ectrician a
License Numbar
� � 763-535-2000 ��,t��,(/ -
INS7RUCl10NS ON BACK OF YELLOW COPY � 80ARD OF ELEC7RICRV COPV EB•0OOO1M14 8.1. 2002