P - 77543�
c �j REQUEST FOR ELECTRICAL INSPECTION
1� Cj �, 1� O J 5 � Minnesota Board of Electricity
. 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW 0 RE�M`g�EL ❑ ADDiTION REP be -using the back of the white c y if nece ary - the work covered by this request:
fi'1 �AX �' ► �'�--Q ��t�� �40S�M l�lD ��
COMMUNICATION, REMOTE CONTROL, SIGI
S, CIRCUITS OF LESS THAN 50 VOLTS
h System Device or Apparatus @ 5.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units
Each Additio
1 BOOm @ $�{(
Park Lots 9
Park Sites p
tion $z
830 cer Fbur
I� III�� I�III IIIII IIII� II�II II�II II�II �� INtl
L6410953
Traffic S' nal Standard $5
Su lemental Fee $20
Transfortners u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns / Outline Li h6n $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
Additional Ins 6on Tri $20
Inves6 ative Fee
Reins tion Fee S20
TOTAL FEE � � r �
(minimum total fee is $20)
. THIS AREA FOR INSPECTpi USE OILY
I hereby tertify thM I inspetOed the electricai insfaN�on described herein on tl�e daBes stated:
ROUC�VIN DAiE
FmNI N$PECiqN ' DATE
�--- 7._ � -
�o� onTE
CTED IF NOT COMPLETED WITHIN 12 MONTHS
nw�� �+�e� Rough-in Inspection Required? ❑ Yes [�JO Inspection Other Than Rough-In: Ready Ncw � yyGl Cal�
�j �`�� You must call the inspector when ready! Date Ready:
I ceiti(y that I am the ' LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER arxi hereby request inspection of tlie electrical work at::