P - 76529REQUEST FOR ELECTRICAL INSPECTION
1� 6� 5- 9 6 6� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Sairrt Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electriciry.state.mn.us
EW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy 'rf necessary - the work covered by ihis request:
!/v'+�L—
GEN L FEES Outdoor Li htin Standard S1
SERVICES / POWER SUPPLIES Traific Si�nal Sfandard � S5
COMMUNICATION, REMOTE CONTROL, SIGNALING
S, CIRCUITS OF LESS THAN 50 VOLTS
h Svstem Device w Aooaratus � 5.50
Trans(ortners over 10 KVA S 20
Transfortner / Power Supply for Siqns I OuUine Lightinq $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Auui i wn5 i u i rtt C;trvtKAL FttS Reins Gon Fee $20
TIFAMILY DWELLINGS PER UNI rn TOTAL FEE
3 to 12 Units �1 a50 Per Unit 7Vb� �(minimUm tOtal fee is $20) 5•
E2Ch Addi6on21 Unit � E25 r�ns u+� Foa uae�cTOa usE aar
I hereby ceNy Mat I inspec�d the electricai insfaNa6on despibed herein on the dates staled:
� OTHER ADDITIONAL FEES CC �
Boom
arfc Lo(s
Hour
Il�ip�lillllllllllllllllllllllilllll��l�
16859662
>
��"� ` Z �J' C
w,e
"`� `� 7 �
CTED IF NOT COMPLETED WITHI
����
�� �
V'�—t�
l�Gg
�� � r:�
� �-� ti
'���� �ej:� Rough-in Inspedion Required? � Yes � No Inspedion Other Than RaugMn: ❑Ready Way VY�I� Call
� i�� 1�/5 You must call the inspector when ready! Date Ready.
I certi(y that I am the LICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request �spection of the electrical work at: