P - 79237` REQUEST FOR ELECTRICAL INSPECTION �
�� Z G Q��� O� Minnesota Board of Electriciry
C7 V O 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� (657) 642-0800 TTY/MRS 1-500-627-3529 www.electriciry.state.mn.us
NEW ❑ REMODEL ❑ ADDITIQN � O REPAI� Descnbg=qs,,�ng,th,g b�k o�el, w, hite copy iF necessary - the wak covered by this request:
0 to 400 Ai
401 to 800
tM, COMMUNICATION, REMOTE CONTROL, SIGNALING
UITS, CIRCUfTS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENER,4L FEES
fIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
Siandard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Suppty up to 500 Amperes, All
Circuits and Two InspecGon Trips Each Dwelling Unit @$80
TOTAL FEE ?p.�O
(minimum total fee is $20}
r�ns arsen rae miscecrae usF aar
I hereby certify ffiat I inspected !he electrical installation described herein on the dates staled:
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Hequest oa[e: Roughin InspeCtion Required? LJ Yes LJ No Inspection Other Than Rough-In: UReady Now U Y�lA1 Call
07��� You must ca0 the inspector when ready! Date Reedy.
I certity that I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elecficai work at::
INBTRUCTONS ON BAGK OF VELLOW COW BOARD OF ELECTRICT' COPV EB-0OOO1M11 8.1.2002