P - 76106REQUEST FOR ELECTRICAL INSPECTION
1�� O�- 0 6 9❑2 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
D@sCrib�'=using the back of the white copy ff ne�� �,e'�� ��y �'��c' S SW T i' C H
A(,ARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
IdULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @$SD Per Unit
Fach Addilional Unit @ $25
OTHER ADDITIONAL FEES
' Retrofit @ $.25 per Fixture
Cer�isr Pivot Irri ation Boom @$40
red Home Park Lots @ $25
' 'Rsciefltionel Vehide Park Sites $5
ar§te Bondi Ins ctlon $20
� ' lnspection $30 r Nour
ial tnsoection nn. $.31 aer Mile
a I II I�I �I II I� 81� �� II III I I III � I� I I lll I�II
1787069�
Traffic Siqnal Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Serrice andlor Power Supply up to 500 Ampere.s, All
Circuits and Two Inspection Trips Each Dvrelling Unft @$80
Investigative fee
Reinspection Fee @ $20
TOTAL
(minimum total fee is
TLLS qREA FO
I hereby certi(y Nat I inspected the electrical
J
dagcribed herein on the
5'�_ �t
TED IF NOT COMPLETED WITHIPI 12 MONTHS __ _____�
. ,�o�-Q��c�
�� Rough-in InspecUon Required7 ❑ Ye f] No Inspe�fion Other Than Rough-In: []{Ready Now 0 Will Call
s' �' �/� 6 You must call the inspector when ready! Date Ready:
I�rpf�r that I am the C� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at