P - 78795REQUEST FOR ELECTRICAL INSPECTION
4 Minnesota Board of Electricity
�� 3 4 I- 318 ��� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 551044
(651) 642-0800 TTY/MRS 1-500-627-3529 � ��V
www.electricity.state.mn.us �
IdentiTy the work covered by this request: 3�/ D
❑ NEW ❑ REMODEL ❑ ADDITION EPAIR ___��� A � ti� ctandard �$1 �
CIRCUITS OF LESS THAN 50
ustem Device or ADParalus �_
Fee � $_ 20 _
uptolOKVA�$10
over 10 KVA � $20
ONE F� TWO hAMILY U11VtLLUV�a, v+..� � ��^ �
I�ludes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$�
Investi tive Fee
Reins n Fee
�n nsrECra+ usE a+Tv
r- f,o�� _
I herebY certiN the� I insp
Sp.°�ial Inspection �$ 31 per Mile I �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF
_ — . FOR OFFICE USE ONLY
I I il I11 I l lll Itll I II lil I II I IIII
I Illlll IIIII Illl11 li
�E 1 3 4 7 3 1 8 6�
Reauest Date: Rough-in Inspection Required? ❑ Yes No Inspec
TOTAL FEE I�/�
(minimum total fee is $20) ��
electripl ir�stallalion described herein on tlie date.s stated:
onh
�=�--��
OMPLETED WITHIN 18 MONTHS
��..� �
, ,e ,� 3���,
.�,.50
Than Rough-In: ❑ Ready N Will Call
� O S You must call the inspector when ready! Date Reatly:
I certiiy that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY �OWNER and hereby request inspection of the electrical work et
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