P - 76501� - REQUEST FOR ELECTRICAL INSPECTION �
�����- 7 7 2� Minnesota Board of Electricity
„. 1821 Univereity Avenue Suite S-128, Saint Paul, Minnesota 55104
�—� (651)642-0800TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
Describe •using the ck of th� wh' copy ii necessary - the work cov�y thisJrequest:
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aretus $.50
ADDITIONS TO THE GENERAL
Per Unit
Each
115 INSTALLATION MAY BE ORDERED
I(II) II III II III II III II III II II) II III II III II �I I I!
19307727
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 (a� $80
Additional Ins ction Tri s $20
Investi etive Fee
Reins ectlon Fee $20
TOTAIFEE
(minimum total fee is $20) '
THI9 AREA FOR INSPECTOR USE ONIY
I hereby certity that I inapeded Me Nectricel instellation descrlbed heroln on Me dates steted:
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I certify that I am the �"LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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