P - 76253REQUEST FOR ELECTRICAL INSPECTION
2�1`j �� o 0 3 � Minnesota Board of Electricity
-��� 1821 University Avenue SuRe 5-128, Saint Paul, Minnesota 55104
• (�51)642-0800TTY/MRS1-800-627-3529www.edectricity.state.mn.us � `�
Desaibe -using tl�e back of e copy'rf n�essary - the work covered by this request:
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/ POWER SUPPLIES
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE COMROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 5U VOLTS
Each Addi�onal Unit @ $25
OTHERADDff10
LiaMirm Retrofit (a� $25 cer Fodure
Hour
Includes the Service andlor Power Supply up to 500 Amperes, M
Circuits and Two Inspection Trips Each Dwelling UnR @$BO
AddNonal Ins 'on Tri $20
Investigative Fee
Reins 'on Fee $20
TOTAL FEE
(minimum total fee is $20) �f�
1H44 Pi�A FOR N6PECTOA U� MRY
I hereby ceAify Umt I mspected the electrical u�te0adnn d� herein on fhe dat� �ted:
IF NOT
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12 MONTHS
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I I� INIIlllllflf�llla�l� ��o �UN — 7 Zoo�
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�1100037
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�� Rough-in Inspectlon Requhed? ❑Yes No Inspection Other Then Rough-In: �Ready N Wm CaII
U� You must cell the inspector w�hen read Da[e Ready.
I certify that I am th� LICENSED CONTRACTOR ❑ COMPANY � OWNER and hereby request inspe�on of the electrical work at
Job Site Street Address _ CRv _
License Number
or Owner P rtning InstaOaUOn) — '
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