P - 77861�:., . REQUEST FOR ELECTRICAl. INSPECTION
`1 -�5 4 4- 6 2 7�1 Minnesota Board of Electricity -
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
/'1� yj' � (651) 642-08Q0 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
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❑ NEW REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back f the white copy if necessary - the work covered by this request:
C� a.� O Clo 1- —��- � g' S�
GENERAL FEES Outdoor Liahtina Standard �$1
0 to 200 Am re $5 t�(" �
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aratus $.50
ADDITIONS TO THE GGMERAIFEES
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ADDITIONAL
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ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Seraice and/or Power Supply up to 500 Amperes, All
Circuits and Twq In`�pection Trips Each Dwelling Unit �$80
` TOTALFEE
i� ' � inimum total fee is $20) • S�
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- 1 lierel�y �Ufy f inspected the electrical installa6on described herein on Me dales stated:
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eciai ms tion m yau �
ecial Inspec6on @ $.31 per Mile - �,
INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPI
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Request Date: Rough-in Inspedion Required? ❑ Yes �No Inspedion Other Than Rough-In: LJReady Now�Will Call
tt- � a-�3 Yau must call the inspector when ready! Date Ready:
I cerfify tt�at I am the �'LICENSED CONTRACTOR ❑ COMPANY 0 OWNER and hereby request inspection of Uie electrical work at::