P - 777191-641-10� [4
❑ NEW ❑ REMODEL ❑ ADDITION �
C�»1 t
GENERALFEES
SERVICES I POWER SUPPLIES
0 to 400 Amcere (� S25
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity �i'yX'_ ��77 ��" :
1821 University Avenue Suite S-128, Sain Pauf;'�uiinnesota ��q�4
' (651)642-0800TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
i EPAIR Describe -� ng the back of the white cA p^ if neces�- th�vered by this request:
,•�/1/�/ V�C
Outdoor Liqhtinq Standard Cd St
CIRCUITS I FEEDERS
0 to 200 Ampere @ $5
Above 2(10 Ampere @$10
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus � 5.50
Unit
Mper de
MAY BE
IIII II Ili II II I I I II I II I I I II I I) II III II III I� I�I
16411084
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each fhMelling Unit @$80
TOTALFEE I
(minimum total fee is $20)
iM15 AREA FOR INSPECTIX3lI5E pLV
I hereby certify that I inspected the electrical installabon described herein on the dates stated:
, _ �E , rz _�.s-
Kequesi uaie: �� Rp�gh�n Inspectian Required7 LJ Yes L�NO Inspedion Other Than RougMn: �Ready Now ❑ Will Call
q�� l, '� You must call the inspedor when ready? �� Date Ready:
I certify tliat I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at: