P - 75884�j w� REQUEST FOR ELECTRICAL INSPECTION
��� 5��� G 2 �1.�' Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55904
(651) 642-0800 TTYlMRS 1-800-62t- 29 www.electricily.state.mn.vs
Descn'be -using the,bagk of the white copy if necessery - the work cover� by this request:
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GENERAL FEES Outdoor Lighting Standard $1
SERVICES / POWER SUPPLIES Traftic Si Standard @$5
0 to 400 Ampere @$25 Suonlemerdal Fee (�D $ZO
Above 2Q0 Am �ere a $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S m Device or A paratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UN
3 to 12 UniLs (d1$50 Per Unit
Boom
S ecial Ins ection @$.37 per Mile
THIS INSTALLATION MAY I
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18558221
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includas ihe Service andlor Pmver Supply up to 5U0 Amperes, All
Circuits and Two Ins�cGon Trips Each Dwellir�g Unit @$80
Additlonal Ins 'on Tri $Z(1
InvestigaUve Fee
Reinsp�on Fee $20
TOTAL FEE ��
(minimum total fee is $20) � 3. Q
TMS At�A FOR U6PELT0I111SE OPll.Y
I hereby certify tl�at I inspeded the ele�4ical trreta0atlon destxbed herefi on the dat� s�ed:
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INECTED_IF NOT COMPLETED WRHIN 12 MONTHS
fOR OFFICE USE ONL'r
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��,� ��� I Rough-in Irrepectlon Requtred? ❑ Yes ❑ No I�p�on Other Than Rough-In: ❑ Ready Nmx� CeII
You must call the inspedor when readyl DaOe Ready.
I certiiy that I am the 0 LICENSED COM�fiACTOR ❑ COMPANY ❑ OWNER and hereby request ins�tion of the electrical work at
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