P - 79203�
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❑ REMODEL ❑ ADDITION ❑
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SERVICES /
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
R Describe :using_the back of the white copy if necessary - the work covered by this request:
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
ADDITIONS TO THE
FAMILY DWELLINGS (PER UI
to 12 Units @$50 Per Unit
ach Addifional Unit @ $25
Retrofit
Outdoor Ligh6ng Sta�dard
Traffic Sianal Standard na '
Inciudes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$BO
TOTALFEE
(minimum total fee is $20) 20,50
THIS AREA Fpt it6PECi0q USE OfIY
I hereby certiy Ihat I inspected the electrical inst�la6on described herein on the da0es sfa0ed:
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Request Date: Rough-in Inspection Required? ❑ Yes ❑ Inspedion Other Than Rough-In: ❑ eady Now � Will Call
����!� You must call the inspecta when ready! Date Ready:
I certify that I am tl�e ❑XICENSED CONTRACTOR ❑ COIu�ANY ❑ OWNER arxi hereby request inspection of the electrical work at::
IN87RUCTONS ON BACK OF YELLOW COPY BOARD OF ELECTRICIT' CAPV E&OOODIMI{ 8.1. 2002