P - 77250,REQUEST FOR ELECTRICAL INSPECTION
1� 6 3 9- 4 2 6� Minnesota Board of Electriaty
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
❑ NEW ❑ REMODEL G}ADDITION ❑ REPAIR Describe -using the back of the white copy 'rf necessary - the work covered by this request:
l�S+u l l e Mer�2n Ua slu�n s�lsi 1c,1.. iv✓ ��:u�1t cti 3na,�n �- ac.cv►.,n�s .
o to 400 /u
401 to 800
CIRCUITS I FEEDERS
0 to 200 Am re ES
Above 200 Am e S10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or atus $.50
ADDITIONS TO THE GENERAL FEES
Units � E50 Per Unit
ddl6onal Unil @ $2S
Retrofit � E.25 oer Fixture
illl II III II III II ( I�I III II III I) II� II III �� I�
16394264
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andla Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
TOTAL FEE
(minimum total fee is $20) 2 �, S b
THIS AREA Fpt INSPECiOR USE p1Y
I hereby cerMy tlwt I inSpecBed the elec6ical inslaMa6on described herein on the dales sta0ed:
' L���`i �
WITHIN 12
� �-=�3��
Request Dale: Rough♦n Inspeciion Required? ❑ Ves No Inspedion Other Than RougMn: ❑Ready Now I,SI'VYAI Call
�-�. ��(�5 Vou must call the inspecta when readyi Date Ready.
I ceAify tl�at I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of tlie electrical wo�C at:
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