P - 78001REQUEST FOR ELECTRICAL INSPECTION
1����-1� O- 8 5 7� Minnesota Board of Electriaty
1821 University Avenue Suite S-128, Saint Pa�d. Minnesota 55104
. � (651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
❑ NEW 0 REMODEL ADDITION ❑ REPAIR Describe -using the bxk of the white copy'rf ne�ssary - lhe work covered by this request:
SERVICES / POWER SUPPLIES
Su demental Fee S20
Tr�sfortners up to 10 KVA @$10
Transfortners over 10 KVA � E 2(1
Transfortner I Power Su for S' ns I Outline L' htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service �dlor Power Supply up to 500 Amperes, All
Circuils and Two Inspection Trips Each Dwelling Unit �$BO
CIRCUITS, CIRCUITS Of LESS THAN 50 VOLTS
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units � a50 Per Unit (minimum total fee is $20)
Each Addi6on21 Unit � $25 TMISMEAFORIt6PECTORU5E011Y
I hereby cer�y tliat I inSpecBed the electrical insfaq�on desxibed herem an
OTHER ADDITIONAL FEES w/
Liah6na Retrofit � 5.25 cer Fi�ure� .. _ / � /� (
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Request . Roughin Inspection Required? �Yes LJ No Inspedion Other Than Rough-In: LJReady Now � Will Call
�� � You must call tAe inspector when ready! Date Ready:
I oertity that I am LICENSED CONTRACTOR ❑ COIu�ANY ❑ OWNER and heieby request inspection of the electrical work at: