P - 78432REQUEST FOR ELECTRICAL INSPECTION
�� 4� 8-� o� � 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 ❑ REMODEL ❑ ADDITION REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
0 to 400 Ai
401 to 800
Above 800
CIRCUITS I FEI
0 to 200 Ai
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
GENERALFEES
TraNic Signal Standard
Suoolemental Fee C� S
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
Additional Insoection Trios � $20
Fee
Fce
fIFAMILY DWELLINGS PER UNI TOTAL FEE ��
3 ro 12 Units @$50 Per Unit (minimum total fee is $20) �—�—
iH15 MFA FOR INSPECiOR USE OKY
Each Additional Unit @$25 I hereby cerEry that I inspecoed the electrical installation described herein on the da� sfaBed:
^ ' OTHER ADDITIONAL FEES N�� ��� �
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RW ��a: Rough-in Inspection Required? ❑ Yes , lo �nspection Other Than RougMn: eady Now ❑ V�ill Call
� 3/ "� You must call the inspector wh� rp,ady! Date Ready.
I certi(y that I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspecUon of ihe elechical wak at:
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