P - 78041REQUEST FOR ELECTRICAL INSPECTION
1— �`t �- 3 5 5� Minnesota Board of Elechicity -
1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
��..j'(� �� (651) 642-OSQO TTY/MRS 1-800-627-3529 www.electricitystate.mn.us
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❑ NEW 0 REMODEL ❑ ADDIT REPAIR De�be -using the back of ihe white copy 'rf necessary - the work covered by this request: �
AIARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus C� 5.50
3 fo 12 Units
Su lemental Fee $20
Transformers u to 10 KVA $10
Transtormers over 10 KVA $ 20
Transformer I Power Su I for Si ns / Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Fee
( TOTAL FE; I � �
minimum total fee is $20
iH15 AREA FOR INSPECTOR USE OKv
I hereby cer6fy that I inspeckd the electrical insfall�on described herein on Me dafes stated:
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S �Ofl $3� f HOUf —-+c c! ExainEOina�rnaiEO ..-- onTE
spection � $.31 per Miie
ALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Request Date: Rough-in Inspection Required? ❑ Yes Inspedion Other Than Rough-In: ady Now O Will Call
' I� I� � You must cali the inspector when ready! Date Ready:
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at: