P - 76163REQUEST FOR ELECTRICAL INSPECTION '
�� 0 6���F � 9 � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� (651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
Describe -using � back of the ite copy ff nec�ary - the ork covered b requesst:
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1MMUNICATION, REMOTE CONTROL
CIRCUITS OF LESS THAN 50 VOLTS
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5 per F6diue
Boom C� $4(
Mile
I�I (� lu u��I I� �II II I�� II II� u I�I II III �� I�
20�74891
Fee
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Suppiy up to 500 Am�res, All
CircuiG4 and Two Inspecfion Trips Each Dwel�r�g Unit @$80
Addfional Ins on Trf $20
Inv�stigative Fee
Reins on Fee $20
TOTAL FEE
(minimum total fee is $20)
THIS AREA FOR PSPECiOR I1SE OM.Y
I hereby cerdry tlmt I inspeded the electrlcal installadon d�atbed herein on fhe daaes s�ted:
FOfi UFFtGE USE ONLY
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Rough-in InspecHon Required? ❑Yes��iVo Inspeclion OtherTh� ��eady Now �WIA Ce8
You must call the inspector when readyl Date Ready.
I certify that I am the LICENSED COPITRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of th� electrical work at
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