P - 78361� REQUEST FOR ELECTRICAL INSPECTION
�- 4 7 5- 2 4 9� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
EW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy'rf necessary - the work covered by this request:
6ENERALfEES
40110 800
Above 800
AIARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
FAMILY DWELLINGS (PEI
to 12 Units �$50 Per Unit
ach Additional Unit � $25
Hour
FEES
Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service �dlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit � 380
(minimum total fee is $20) � �/—
TM6MEA Fpt IlEFECTdi USE QLY
I hereby catify that I inspecBed the electrical i�talladon desaibed herein on the da�s sf�ed:
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I c�rMy that I am the
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CONTRACTOR ❑ C�ANY ❑ OWNER and hereby request �spection of tlie electrical woiic at:
INSTRUCTOMS ON
�-OOODtM14 8A.2002