P - 78885I
1—,6 � 7- 5 5 5❑7 REQUEST FOR ELEC�TRICRL INSPECTION
Minnesota Board of Electrici
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-08Q0 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
❑ NEW ❑ REMODEL ❑ ADDITION ❑ RE�PAIR Describe -using the back of the white cqpy 'rfpecessary - t�e work red�y�s� que�t:
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CIRCUITS OF LESS THAN 50 VOLTS
iYStem Device or Aooaratus &il A 5n
3 to 12 Uni6c �$50 Per Unit
Each Additional Unit � $25
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Indudes the Service and/or PpMrer Supply up to 500 Amperes, All
Circuits and Two InspecGon Trips Each Dwelling Unit � S80
Additional Inspection Trips $20
� Inves69aGve Fee
TOTAL FEE I
(minimum total fee is $20)
nnsut�, Fat ua�cTaa us� aar
I hereby cerMy Ihat I inspecfed the electrical inslaA�on despibed hmein on the dartes sf�ed:
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��e' Rough-in Inspection Required? ❑ y�
No Inspection Other Then Ragh-In: ady Now � Will Call
Z � l" You must call the inspectur when ready!
Date Ready.
iat I am the LICENSED CONTRACTOR ❑ COMPAWy ❑ pyyNER and hereby t inspection of the elecbica� work at:
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