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� ❑ ClEW `QfiEMODE,� ❑ ADDITION ❑
GENERALFEES
SERVICESiI
0 to 400
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
REPAIR Describe -using the back of the white copy if necessary - Ne work covered by this re
USc�� �.7 S i .�' ?7%' �Y�.S
Outdoor Liahtina Standard � $1
Above 200 Ampere @$10
tM, COMMUNICATION, REMOTE CONTROL
:UI7S, CIRCUiTS OF LESSTHAN SOVOLTS
Each Svstem Device or Apparatus �$.50
TIFAMILY DWELLINGS (PEI
3 to 12 Units �$50 Per Unit
Each Additional Unit @ $25
Fixture
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ONE 8 TWO FAMILY DWELLINGS, EACH UNI7
Includes ihe Service �dlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
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TOTALFEE
(minimum total fee is $20) �
TItlS MEA FOR NSPECTpI USE pir
1 hereby cer0y Mat I inspected the electrical instaN�on Aescribed haein on the da�s sf�ed:
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ReQu/es�l D�e: Rough-in Inspection Required? ❑ Yes InspeUion OtherThan Rough-In: �Ready Now�ll Call
'/ i�� You must eaN the inspeda when ready! pate Ready.
I cerMy that I am ttie �CICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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