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P - 81569REQUEST FOR ELECTRfCAL INSPECTION Minnesota Board of Electricity � 1� 0��� 3 5 4� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 (651) 642-OS00 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us Itlentify the work covered by this request: ❑ NEW $REMODEL ❑ADDITION ❑ REPAIR GENERAL FEES SERVICES / POWER SUPPLIES 0 to 400 Am ere �$25 401 to 800 Am re C� $50 Above 800 Am ere (� $75 CIRCUITS / FEEDERS l 0 to 200 Amoere ��5 l e r n e.+ r IICATION, REMOTE CONTROL, ITS OF LESS THAN 50 VOLTS Device or Apoaratus � $.50 Unit � 9 OTHER Vehicle Park Sites � idin9 Insoection � $� 1C�G`t'ii��C/'I�' `�f,C 171�Gt'i Supplemental Fee � $20 Transformers up to 10 KVA � Transformers over 10 KVA � ONE & TWO FAMILY DWELLINGS, EACH UNIT Includes the Service and/or Power Supply up to 500 Amperes, All Circuits and Two Inspection Trips Each Dwellin Unit �$8( Additional Inspection Trios � $20 Fee total fee is 1 herebvi cerdiv that I inspected the electrical inshallation described herein on the dates stated; Ron o�ce usE oN�r � ���ill ��I�� ����� ����� I���I ��� ��I�� �III ���� �4 1 O 5 3 3 5 4 5�E Request Date: Rough-in Inspection Required? ❑ Yes ❑ No Inspection Other !`�! /�U� You must call the inspector when ready! Date Ready: v � )MPLETED WITHIN 18 MC .�� � � IZ S.�u I certify that I am the [�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the slectrical wodc at: