P - 78964� REQUEST FOR ELECTRICAL INSPECTION
1. - 6 8 7���� � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electriciry.state.mn.us
0 NEW ❑ REM O ADpI ON ^0 REPAIR Describe -using the�back of the�vhite copy if necessary - the work crovered by this request:
0 to 400 Ai
401 to 800
10 Am re 35 ONE & TWO FAMILY DWELLINGS, EACH UNIT
200 Am re $10 Includes the Service and/or Power Supply up to 500 Amperes, All
)MMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Tnps Each Dwelling Unit @$80
CIRCUITS OF LESS THAN 50 VOLTS Additional Ins Gon Tri $20
i stem Device or atus $.50 InvesG ative Fee
ADDfTfONS TO THE GENERAL FEES Reinscection Fee C� 820
3 to 12 Units @$50 Per Unit (minimum total fee is $20) � �'��
Each Addi6onal Unit @ $25 . / ,
THis naFn Fon ira�croa use
I hereby cer6y that I inspected the electrical installa6on described herein on the dates siated:
OTHER ADDITIONAL FEES � V �� �� G� � 7 6�
Lighting Retrofit p$25 per Fixture
F�
� TFi15 INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS �
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Req t Date: Roughin Inspection Required? ❑ Yes ❑ No Inspection Other Then Rough-In: y Now 0 WNI Call
� � ` O You must call the inspecta when ready! Date Ready.
I certify that I am the LICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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INS7RUCTONB ON
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BOARD OF ELEC7RICITY CAPV
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License Number
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EB-0OOO1M14 8.L2002