P - 780611 REQUEST FOR ELECTRICAL INSPECTION
�1 - 5 3� 1-10 6�1 Minnesota Board of Electriaty
- 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
��� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW �ifEMODEL O ADDITION 0 REPAIR Describe -us� t� back ���=opy 'rf n J- the worlc covered by mis request:
l �
GENERAL FEES Outdoor Li htin Standard $1
SERVICES / POWER Sl1PPLIES T�,. c,..,�i e��..a�..� � ec
)MMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
Ystem Device or Apparatus @ E.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units
Each Additioi
I�OUf
to 10 KVA
:r 10 KVA
ONE & TWO FAMILY DWELLINGS, EACH UNIT '
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unil �$80
Addition� Ins tion Tri S20
Inves' ative Fee
Reins tion Fce $20
TOTAL FEE
(minimum total fee is $20)
iH15 AREA FOR NJSPECTpi USE OILY
I hereby certify tlw41 inspec0ed 1he �yl insfall�on d¢scriped herein on the dates stated:
st uKUeReo p�scoNNECTED IF NOT COMPLETED WITHIN 12 MONTHS
lUl N III II ill II III II III II I!! II III II �I N� I�
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�ay�� .,a�o. ROUghin Inspection Required? ❑ Yes '�lo �nspe�}ipn p�her Than Rough-In: ❑Ready Wow 11 Call
��,� ���� You must call the inspector when ready! pete Ready.
I certify that I am the �ICENSED CONTRACTOR �COMPANY ❑ OWNER and hereby request inspection of Ihe electrica� work at: