P - 776211 H� 1 O 2 9 "� REQUEST FOR ELECTRICAL INSPECTION ����
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� � � Minnesota Board of Electricity �;
,s 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
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• (651) 642-0800 TTY/MRS 1-800-627-3529 xnvw.electricity.state.mn.us �<�s�
Describe -using the back of the white Sppy if necess�ary - the wor �vered by,�his re st: ��
ilF/ �
0 to 400 Ar
401 to 800
Above 800
;UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
TIFAMILY DWELLINGS (PER UNIT)
3 to 12 Units @$50 Per Unit
Manufactured Home Park Lots �
Recreational Vehicle Park Sites
Standard (a? $1
Transfortners over 10 KVA $ 20
Transformer / Power Su I for Si ns I Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ection Tri s $20
Investigative Fee
Reins ection Fee $20
TOTALFEE �j�
(minimum total fee is $20) �Ku.�'s`v
THISAREAFORINSPECTORUSEONLV ^ , �
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I hereby certiry that I inspeded the elecVical installation described herein on the dates stated:
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rou h in Inspedion R uired?
�� �D `Q� g= eq ❑Yes No Inspection OtherThan Rough-In: Ready Now ❑Will Call
You must call the inspector when ready! Date Ready:
I certify t at I am tI�LICENSED CONTRACTOR ❑ COMPANY � OWNER and hereby request inspection of the electrical work at
Job Site Street Address Cky �
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