P - 79211� REQUEST FOR ELECTRICAL INSPECTION
�� 7 6 8-� 3 3� Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� (651) 642- 0 80 0 T f Y/ M R S 1- 8 0 0- 6 2 7- 3 5 2 9 www.e lec trici ty.s ta t e. m n. u s
NEW O REMODEL ❑ ADDITION ❑ REPAIR Describe -usin the back of the white copy if necessary - the work covered by this request:
}CGEL ENERGY SAVE�'S SWfTCH
POWER
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 5D VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @
Each Additional
Liahtino Rehofit
Traffic
Fee
up to 1f
over 10
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
Additional Inspection Trips @ $20
� Invesliaative Fee
TOTAL FEE I
(minimum total fee is $20) ��•`�0
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I hereby certify that I inspecled the electrical installa6on described haein on the dates staBed:
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Request Date: � Rough-in Inspection Requiretl? ❑ Yes O Inspecfion Other Than Ragh-1�: ❑ dy Nnw � Will Call
����� You must call the inspector when ready! Date Ready.
I certi(y that I am the �CICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of tfie electrical work a�:
INS7RUC710NS ON BACK OF YELLOW COPY BOARD OF ELECTRICITV CAPY E&OOOUTA-11 &1.2002