P - 78622Q REQUEST FOR ELECTRICAL INSPECTION
`1 � 3 9 9� V 8 0 � Minnesota Board of Electricity
���� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW , EMODEL ❑ ADDITION ❑ REPAIR Describe -us/ing the back of the white copy'rf necessary - the work covered by this request:
� 1�i1�.. ��/�w//Vi�'l /�..���7�l�l� ��i�S
GENERALFEES
0 to 400 Ai
401 to 800
Above 800
:UITS I FEI
— � Hoove �uu r+mpere �� iu
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per
Each Additional Unit @ 1
Fixtute
ONE & TWO FAMILY DWELLINGS, EACH UNIi
Includes the Service andlor Power Supply up to 500 Amperes, All`
Circuits and Two Inspec6o� Trips Each Dwelling Unit �$80
(minimum total fee is $20) � �(/i �J
THISARE�Fd3W5PECT0itU5Ed1Y �
I hereby ceAiy tlwt I inspecled the elecbical i�talla6on described herein on the dates staBed:
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IIIIIIIII IIIII IIIII IIIII��a���N� I�
L3998802
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Request Date: /� Rough-i� Inspection Required? ❑ Yes C�O Inspe�ion Other Than Raugh-Irc UReadyNOw �y1VfII Cell I
ti��—V� You must call lhe inspec[or when readyl Date Ready. .
I certify that I am Uie ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby iequest inspection of the e�ctrical worlc at: