P - 777401-633-275 ❑1
❑NEW REMODEL pADDITION ❑ �
0 to 400 Am ere L25 � d v
401 to 800 Ampere @ 550
Above 800 Ampere (al b75
CIRCUITS I FEEDERS
0 to 200 Amcere (� $5 �,F.�' (�
Above 200 Ampere p$10
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus � 5.50
3to12
��I�
Hour
Mile
IIIII IIIII Ilill IIIII I{III IIIII IIIII IIIII �� I�I
1 6 3 3 2? 5 1
REQUEST FOR ELECTRICAL INSPECTION
Minnes.`"°° ....., 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
R Describe -using the back or the white copy 'rf necess�y - the work covered by this request:
"� �c✓'✓�'c� ���w �
Traific Signal Standard
Supplemental Fee @ $
Transformers uo to 10
ONE � TWO FAMILY DWELLINGS, EACH UNIT
Includes lhe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Addifional Inspection Trips � $20
investiaative Fee
TOTAL FEE I
(minimum total fee is $20) ��j, �
THISFREAFIXtINSPECTORUSEIXJIY �
I hereby cer6ry that I inspec0ed the elec4ical insiallafion described herein on tlie dates stated:
D IF NOT GOMPLETED WITHIN 12 MONTHS _�
��- �zi �
ecequesc ace: Rough-in Inspection Required? ❑ Yes J� No Inspection Other Than Rough-In: ❑Ready Now Will Call
os ` -
You must call the inspecta when ready! Date Ready:
I t I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of Ihe electrical work at: