P - 78464/� REQUEST FOR ELECTRICAL INSPECTION
1��t ��- 419 ❑7 Minnesota Board of Electricity O
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
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1�(,ti� (651) 642-0800 TfY/MRS 1-800-627-3529 www.electricity.state.mn.us ,
NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using Ne back of the white coPy if necessary - the work covered by this request:
FEES
SERVICES /
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
to 12 Units @$50 Per Un
ach Additional Unit @ $25
Fixture
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L4334197
� Transfortners up to 10 KVA �$10
� Transformers over t0 KVA (o� $ 20
Transformer / Power Supply for Signs / OuUine Liqhtinq $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Suppiy up to 500 Amperes, NI
Circuits and Two Inspection Tnps Each Dwelling Unit �$8(1
_ (minimum total fee is $20) � �� ��
THIS AREA FP4 MlSPECTdi USE OIRY
I hereby certiry that I inspected the elecErwal install�on described herein on Uie dates sqled:
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Request e: Rough�n Inspection Required7 ❑ Yes Inspedion Other Than Rough-In: ❑Ready Now �VYII Call I
��'� s(�� You must call the inspecta when ready! Date Ready:
I certify that I am the �ICENSED CONTRACTOR OCOMPANY ❑ OWNER and he�eby request inspection of ttie electrical wo�C at: