P - 76097REQUEST FOR ELECTRICAL INSPECTION
1� 7� 9- 7 0 6�7 Minnesota Board of Electricity �;
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using e ack of the whfte copy ff necessary - the work cover�by this request:
SUPPLIES
ALRRM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRGUITS, CIRCUITS OF LESS THAN 50 VOLTS
� Each Svstem Device or Aaaaratus (�D $.50
Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Inciudes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE ��
3 io 12 Unns @$50 Per Unft (minimum total fee is $20)
EaCh Additi0n81 UI11t @ $25 nnsr,a�aFOaws�cronuseanv
OTHER ADDITIONAL FEES
Lighting Retrofit @$25 per F'ucture I hereby certity that I inspected the elecVical instellaGon described herein on the dates steted:
Center Pivot Irrigation Boom @$40 aou�+w on,�
PAanuFactured Home Park Lots $25
Recreational Vehicle Park Sites $5 F�uwsPecnau onre �
Se rate Bondin Ins ction $20
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Special Inspection @ $30 per Hour °w°tE01 °ATE
Special Inspection @ $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Rough-in Inspection Required7 ❑Yes �o Inspecdon OtherThan Rough-In: ❑ Ready Nowg(Will Call
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� You must call the inspec[or when readyl Date Ready:
I certiiy that I am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Sft�Street Ad ss p ` �---
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Licenae Number Master Electrician or P
Licenae Number
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�se Prowde Txro (2) Phone
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