P - 77568��
_1--�57-145 �
❑ NEW ❑ REMODEL ❑
0 to 400 A�
401 to 600
REQUEST FOR ELECTRICA INSPECTION
Minnesoha Board of Electriaty �oQ�,—b�/��
1821 University Avenue Suite 5-128, SaiM Paul, Minnesota 551
(651)642-0800llYlMRS t-800-627-3529 www.electriciry.state.mn.us
Z�.T.�-._.e��fT�— lcJ�.�' ���/�
u ro zuu nm re
Above 200 Am e $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or atus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @ S50 Per Unit �
i�il
OTHER ADDITIONAL FEES
��II �) II) II �II II III II (II II (I� II �II II III ��� I�
1 6 5 7 1 4 5 7
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes tl�e Service anNw Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @ SBO
( TOTAL FEE I =/ �L
minimum total fee is $20 `�-y-s
iW5 MEA FOR N/SPECTOR USE OILY
I hereby cer5(y tl� I inspec6ed the dec6ital instalaion described h¢e��ein an da0es
8 �. �
—� A
FIWL 1SPECipN E � /
�� G ✓
E%PIRED/ WTE
CONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
f,,, °
�� � _, ,
6�� -7 ?7 -7�'��
� / Rough-in Inspection Required? LJ Yes I�hb Inspe�tion Other Than Rough-In: �Ready Now B'QiAll Call
Z� � 5 ou must call the inspeclor when ready! pate Ready.
I certiTy that I am Uie ICENSED CONTRACTOR OCOMPANY ❑ OWNER and hereby �equest inspe�,ian of the electrical work at•: