P - 79092REQUEST FOR ELECTRICAL INSPECTION ��
1� 6 8 5- 814 � Minnesota Board of Electricity
y 1821 University Avenue Suite S-128, Saint Paui, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
NE .� REMODEL ❑ ADDITION 0 REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
` .,
NERAL FEES Ouidoor Li htin Standard $1
SERVICES I POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Am re $25 Su emental Fee $20
.n, �., onn n.....e.e n ecn Transformers uo to 10 KVA �$10
AIARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aratus $.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
aTHER ADDITIONAL FEES
I Home Park
Vehicle Park
ONE � TWO FAMILY DWtLLIN(iS, tAl:ti UNI I
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
�--�� j(r�inilnum total fee is $20) � �v �
THIS AREA FIXt INSPECTOR USE IXiY
I hereby cer6ry at I i the elecbical installaUO described herein on the dates sfaled:
�/.�)�°��1�-� � - , � ,3-��
ms'.'�
. _ ------------------- �i� , �
� ���� �) ��� �� ��� �� �i� �(�� I� ��� I� ��� �) ��� ��� �� �
�� �
1 6 8 5 8 1 4 4 �� �
Request Dffie: Rough�n Inspection Required? Yes ❑ No Inspection Other Than RougMn: OReady Now Will Call
' I—'�� d� You must call the inspecta wNen readyl Date Ready.
I certify that I am the LICENSED CONTRACTOR �COMPANY ❑ OWNER and he�eby request inspection af tl►e electrical wwk at:
Job Site Address (Stree1. Box a Roule ) CiIY ` LP �
�.��Z W�(�J��� � `� ~vY
,..r .m.� .. . ..., u
5�33 v
ne Please Provide Two (2) Phone Number(s) Indudirn
o� � �p,�1 �i� ►�C� �3)"ls7 -�32c�i )
a
l°►�I � �
� � ��i C
��� �����,
� ��-�- �► �J
i � ,,d_-�w� V �( �oo iv�-
INS7RUC710NS ON BAGK OF YELLOW COP1/ BOARD OF ELECTRICITV COPY
w-t- � �-S
se Number M ter Electriden a Power Limited Technician
�/ �Q Lioense Number
�O �
�� R � � r��
�,«,a cs>
��3� S3—Oa1
EB-00001M14 8.1.