P - 757701 7 81 918 � REQUEST FOR ELECTRICAL INSPECTION
� � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 wnnv.edectricity.state.mn.us
Descrfbe -usinQ the back of the white copy'rf nec�ssa�dl! -Lthe �e,�i.by�ig �gup� ;� �� T C H
tAlrt Liv H G{z
GENERALFEES
�
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Eech S stem Device or Ap aratus @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Per Unit
Park Lots �
Park Sites
'ALLATION MAY BE
lllll I
II UI II IN I I� II I� ��I II III II �II II IN I IIII
17819186
Traffic Siqnal Standard
� Transformer / Power Supply for Signs / Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Insoection Trlos an $20
TOTAL FEE ��,
total fee is $20)
I inspeded the electrical Installation d�cribed herein on the dates staled: I
IF NOT
�� �°` �/ �.� �
��%_.._�� I
MONTHS
"a`B' Rau h-in Ins ection R uired?
g p eq ❑ Yes �] No Inspecbon Other Than Rough-In: [�;Ready Now ❑UWI Call
�'j��/og Youmustcall[heinspectorwhenreadyl DateReady:
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
H�ISTRUCTIONS ON BACK OF YELLOW COPY BOARD OF ELECTRIGTY COPY E&OOOO�A-15 a 1�ne