P - 78951REQUEST FOR ELECTRICAL INSPECTION
1�� 5 7- 4 6 9 � �innesota Board of Electricity -
1821 University Avenue Suite S-12B, Saint Paul, Minnesota 55104
' �651) 642-0800 TTYlMRS 1-800-627-3529 www.electricity.state.mn.us
0 NEW REMODEL 0 ADOITION. ❑ Describe -using ihe back of the white copy 'rf necessary - the work covered by ihis requesi:
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SUPPLIES
GRCUITS
over
0 to 200 Am re $5 ONE & TWO FAMILY DWtLUNGS, tnGn um i
Above 200 Am ere $10 Includes ihe Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspec6on Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Addi6onal Ins tion Tri $20
MILY DWELLINGS PER UNI TOTAL FEE �� f> w�
12 Units � S50 Per Unit (minimum total fee is $20) (J
lAddl6onalUnit $25 *wsu+�wFwna�cToausEOrar
� I hereby cerUry that I i�pecBed Uie elec6ical insbNa6on descrihed h�n on tl�e da�s st�d:
OTHER ADDITIONAL FEES Z �.� �:�, _ G j���
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Re4�es� ' Roughin Inspection Required? ❑ Yes No Inspecfion Other Than RougMn: y Now � VWI Cell
�J %�f!/�..a�V � You must call the inspector when readyl pate Ready;
I certify Ihat I am ihe �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and heteby request inspection of Vie electrical wak at:
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