P - 76638REQUEST FOR ELECTRICAL INSPECTION
1� 7 3 3- 4 3 0 1� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-0800TTY/MRS1-800-&27-3529 www.electriciry.state.mn.us
❑ NEW ❑ P�M��EL O ADDITION ❑ REPAIR Describe -using the back of t e whi►e copy'rf necessary - the work covered by this request:
"�� 4� �GO
GENERAL F S Outdoor Li htin Standard $1
SERVICES I POWER SU PLIES ,� Traffic Sinnal Standard � E5
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or alus S•50
ADDITIONS TO THE GENERAL FEES
2 Units � $50 Per Unit
Additional Unit @ E25
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I I�I II hl I! � p ll► !! �!I II I� � I� II ql N� I�i
17334301
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes tt�e Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
TOTAL FEE
(minimum total fee is $20) ,30 � sv
TXI$ NiEA FOR IIbffCTOR USE dLY
I hereby cer6fy th� I inspected the electrical installaGon described herein an the dales stated:
IF NOT
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� Roughin Inspection Required? U Yes �No Inspection Other Than Rough-1�: ❑Ready Npw D Will Call
( 2 1 � 6 You must call the inspedor when ready! Date Ready. ,
I certiy that I am the f� LICENSED CONTRACTOR ❑ CON�ANY ❑ OWNER ar�d hereby request inspec6on of the electrical work at::
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