P - 772751-726-158. �
❑ NEW ❑ REMODEL DI N ❑
, f
GENE LFEES
SERVICES / POWER SUPPLIES
0 to 400 Amcere Cd 825
Above 200 Am re �$10
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity -
1821 University Avenue Suite 5-128, SaiM Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electriciry.state.mn.us
2 Describe iny the bx of the white copy 'rf necessary - the wak covered by this request
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Senice andla Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @ E80
AILY DWELLINGS PER UNI TOTAL FEE D
2 Units @$50 Per unit (minimum total fee is $20) '
rws u+� Foa ws�cTaa usE
Addi60n� Unfl � S25 I hereby ceNy tlwt I inspec0ed the elechical instaqa6on described herein on the dates stated:
OTHER ADDITIONAL FEES � �� �^ � �� `
na Retrofit � 5.25 oer Fi�ure (O
rigation Boom � $4C
Home Park Lols @ S
'ehicle Park Sites p'
ling Inspection @ $21
tion 61 E30 oer Hour
I IIII II �I II lu II �I I� �!! II II I II ill II III ��(�H
1726L587
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ecequest uace: hin Inspedion Required? LJ Yes Ll No Inspedion Other Than Rough-In: �Ready Now ❑ WNI Call
��a �� '� Vou must call the inspeqa when ready! Date Ready. .
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I certify that I am the LICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of ihe electrical work at:
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COOiI
.ECTRIC, INC.
�"'�"^'�' ing
MN 55433
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Please Provide Two (2) Phone Number(s) In
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Master necttiaan a
License Number�
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