P - 75995Q REQUEST FOR ELECTRICAL INSPECTION � ,
1 6 2�� ��J � Minnesota Board of Electricity �
1821 UnNersity Avenue Suite 5128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-�27-3529 www.edectricity.state.mn. us
the back of white co iF necessary - the work covered by req
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tM, COMMUNICATION, REMOTE CONTROL, SIGNALING
URS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDI170NS TO THE GENERAL FEES
fIFAMILY DWELLINGS (PER UNI'�
3 to 12 Units na $50 Per Unit
Park LoLS
iALLATION MAY BE ORDERED
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19623198
Transfortners rner 10 KVA $ 20
Transfomrer / Power Suppty for Signs / Outline Ughting @$5
ONE & 1W0 FAMILY DWELLINGS, EACH UNR
Includ� the Service and/or Power Supply up to 500 Amper�, A�
Circuits and Two Ir�s{�on Trips Each Dwelling Unit @$80
Addi�onal Ins �ection Trips @ $20
Irnestlgative Fee
Rems ec�tion Fee $20
TOTAL FEE
(minimum total fee is $20) A
THIS AI�A F0.R U6�TIXi USE OMY
I hereby ceN(ythet I Nspec[ed the eleetrh�l inslellatlon de�ai6ed herehi on tlre
�IPLETED IMTHIN 12 d10NTHS
FOR C�('FI�E USE (!NL'i
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��' Rough-in Inspection Requtred? ❑ Yes 0 No Inspedion Other Than Rough-In: 0 Ready Now ❑ Will CaII
� You must call the inspector when readyl Date Ready.
I certidy that I am the LICENSED CONTRACTOR ❑ COMPANY � OWNER arid hereby request mspec�ion of the electrical wrork at
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