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I'o NFW� MODEL ❑ ADDITION ❑
FEES
401 to
REQUEST FOR ELECTRICAL INSPECTION
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
REPAIR Descnbe -using the back of the white copy if necessary the work covered by this re�
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CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units � 5bu rer um
Each Additional Unit � S25
II��I III� II�II II�I� III� �� �� �� �� I�
143�1261
Traffic
ONE & TWO FAMILY DWELLINGS, EACH UNIT
includes ihe Service andlor Power Supply up to 500 Amperes, All
Grcuits and Two Inspection Trips Each Dwelling Unit �$80
Fee
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(minimum total fee is $20) � Iw"
THIS MEA Fq21N5PECTOR USE IXJIY
I hereby cer6ry 1h� I inspeckd tlie elecUical ir�stalla6on described herein on the d�s stated:
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R����� Rough�n Inspection Required? ❑ Yes No Inspedion Other Than Rough-In: OReady Now�'V�il� CeW
You must call the inspector when ready� Date ReadY'
I ceRi(y that I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and heieby request inspection of ihe electrica� wak at:
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INS7RUC" �JNB ON BACK OF YELLOM� COP`!
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COPY