P - 78440c Q REQUEST FOR ELECTRICAL INSPECTION
1� 4 9 0� V O v � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
" (651) 642-0800 T'fY/MRS 1-800-627-3529 www.electricity.state.mn.us
N ❑ RfiNODEL ❑ ADDI710N ❑ REPAIR Describe -using the back of the white c y if neces - the work covered by this request: /. �
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GENERALFEES
401 to 800
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
MULTIFAMILY DWELLINGS PEI
3 to 12 Units �$50 Per Unit
Each Additional Unit @ $25
FEES
ing Standard
Standard (�a
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlw Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
TOTALFEE �
(minimum total fee is $20) O' p�
THIS MFA FOR INSPECTOfI USE OILV
I hereby cerUy that I inspec0ed the electrical insiallation described herein on the daBes sta�d:
S iallns 6on $.31 Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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14906085 �
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Request Date: Rough-in Inspection Required? ❑ Yes Pb Irapection Other Than Rough-In: ady Pbw ❑ VWII Call
/Q � —Q 3 You must call the inspeUar when readyl Date Ready: .
I certiiy that I am the �1 LICENSED CONTRACTOR ❑COMPANY ❑ OWNER arxi hereby iequest inspection of tlie electrical wak at:
Job Site aress (Streel, smc or Ra,te No.) ' �r %"/ % / / ��¢�� �i
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Sec�ion Township Range Fire No. Cou
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mtrectar / Campan
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ailing Address (Coi
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np�y or
Please Provide Two (2) Phane Number(s) Induding Area Code
/1%� �163)l�3�'� S�� )
ower SuPPlier Address
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ConMad/o�r Lic�se Number Masler Electridan a Limi6ed Tedmidan
t� `-' +� O L �( � License Number
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rtning Instellatan)
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_ IN87RUC' �ONS ON BACK OF YELLOW COPY BOARD OF ELECTRICIT' COPV
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