P - 77223REQUEST FOR ELECTRICAL INSPECTION � ,
1- 615 - 0 3 3� Minnesota Board of Electricity
182t University Avenue Suite S-128, Saint Pa�, Minnesa�fa 55104
(651) 642-0800 TTY/MRS 1-800�627-3529 www.electricity.state.mn.us
❑ NEW O REMODEL ❑ ADDITION EPAIR -�De�escribe -using the baek oi ihe white 'rf necessary - the covered by ihis request:
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ALARM, COMMUNICATION, REMOTE CONTROL
GRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device w Aooarffius Cd E.50
3 to 12 Units
Mile
Trans(amers u to 10 KVA E10
Transfortners over 10 KVA � S 20
Transfortner / Power Supply for Signs I Outline Lqhting � E5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling UnK @ i80
Inves6 ative Fee
Reins ' n Fee E20
TOTALFEE
(minimum total fee is $20) Z���
THLS NIEA FOR REPECTOR USE OILY
I hereby cer6fy that I inspected tlie electrical i�falla6on described herein on the dates sfated:
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I nequasc uace: I Rqrghin Inspectlon Required't LJ Ves 13'Fb I I�pedion Other Than Rough-In: ❑Ready Now �N�ill Call l
You must call the inspecta wF�en ready! pe� �y: I
I oertify that I am the �ENSED CONTRACTOR ❑CObPANY ❑ ONMER and hereby request inspe�;6on of the electrical wak at: