P - 78260REQUEST FOR ELECTRICAL INSPECTION
1� 415 - 7 5 5� Minnesota Board of ElecVicity -
1821 University Avenue Suite S-128, Sairrt Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW O REMODEL ❑ ADDITION ❑ REPAIR Describe -using the b�k of the white copy if necessary - the work covered by this request:
Tratfic Sianal Standard
u to zuu Am re Sb ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins tion Tri s $20
Ea�h S stem Device or ratus $.SD Investi a6ve Fee
ADDITIONS TO THE GENERAL FEES ` Reins tion Fee $20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units @$50 Per Unit (minimum total fee is $20) � e, �
Each Addi6onal Unit @$25 rws naEn Fat iNSaECroa usE onr
I hereby tertify that I inspected the electrical insialla6on described herein on the dates sfated:
Retrofit
� Special Inspection @$.31 per Mile I I
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WIT
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JN 12 MONTHS
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Request Dat : Rough-in Inspection Required? O Yes Inspedion Other Than Rough-In: ❑Ready Nav II Call
� � 5 You must cali the inspector when readyl Date Ready:
I certify ihat I am ihe �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of ihe electrical work at::