P - 77141REQUEST FOR ELECTRICAL INSPECTION P
1�� 1 L� � g 0 8 �,, Minnesota Board of Electricity �� �
. � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �'
(651) 642-0800 TTY/MRS 1-800-6273529 www.electriciry.state.mn.us
Describe -using the back of the white copy if necessary - the work cov ed by this request:
n.�nt �%-- - � -�--�_. � D . � .I . � .
0 to 400 Ai
401 to 800
Above 800
CIRCUITS / FEE
0 to 200 Ar
� CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
ADDITIONS TO THE GENERAL FEES
iIFAMILY DWELLINGS (PER UNIT)
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Liqhtinq Retrofit (o? $.25 oer Fixture
Outdoor Lighting Standard
Traffic Siqnal Standard f�a
� Transformer / Power Supply for Signs / Outiine Lighting @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiqative Fee
inimum total fee is $20)
I hereby certiy that I inspeded the elecUical installaGon described herein on the dates stated:
r��.�.
Hour
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITFHN 12
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I III) II III I� I�) I) III II � I(I III II (I II III II III I(��I
19L69085
Rough-in Inspection Required? �es ❑ No Inspection Other Than Rough-In: ❑ Ready Now�Will Cali
�� � 3"�,� You must call the inspector when ready! Ddte Ready:
I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at