P - 79218REQUEST FOR ELECTRICAL INSPECTION
�� 1 V�- 5 4 4� Minnesota Board of Electricity -
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651)642-08001TY/MRS 1-80D-627-3529 www.electriciry.state.mn.us
NEW ❑ REMODEL ❑ Ao�irXCEI�. ENERGY SAVE�h$by kWof�e�Hte copy if necessary - the work covered by this request:
GENERALFEES
Traffic Sianal Standard
0 to 200 Am re $5 ONE & tW0 FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes the Service and/w Power Supply up to 500 Amperes, All
AIARM, 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 $20
Each Svstem Device or Aooaratus �$.50 Investiaative Fee
3 to 12 Units @$5Q Per Unit (minimum total fee is $20) I �0.50
Each Additional Unit @$25 r�xs uu� wa �c.ca usE aar
I hereby cer9fy thal f inspected the electrical instad�on described herein on the dates sta6ed:
OTHER ADDITIONAL FEES
Uahtina Retrofit (al $.25 cer Fixture � d"�"� a 1�'7 3
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LLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED 1MTHIN 12 MONTHS _
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Request Date: I Rough-in Inspection Required? ❑ Yes ❑�PIo Inspedion Other Than Rough-In: ai�eady Now 0 Will Call
����4 Yau must call the inspector when ready! Date ReaCy:
I certify that I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER arni hereby request inspection of the electrical work at:
INST1tUCTONB ON BACK OF YELLOW COPY BOARD OF ELECTRICRY COPY EB•00001A-14 8.1. 2002