P - 76136REQUEST FOR ELECTRICAL INSPECTION �`'
1� V��- 918 � 1A821 Un'�rvtersily Aven�ue 3uite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 "I7Y/MRS 1-800-627-3529 www.electricity.state.mrr.us
Describe -using the back of the white copy If ne�sary - the work covere�i by this r�uest:
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�-' GENERAL FEES Outdoor Liahtirm Standard C� $1
RCUITS / fEEDERS
0 to 200 Am ere ,$5
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG'
CIRCURS, CIRCUffS OF LESS THAN 50 VOLTS
Each S em Device or aratus @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS ER UN
3 to 12 Unfts @$50 Per Unit
Each Additional Unit (�D $25
MAY BE ORDERED
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18859181
Fee
Includes the Service and/or Powrer Suppiy up to 500 Amper�, All
Circ�uits and Two Inspe�ion Trips Each Dwelling Unit @$BO
Addfionallns 'on Tri $20
Investi ative Fee
Reins 'on Fee $20
TOTAL FEE @ � ��
(minimum total fee is $20) 3
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I hereby certify that I inspeded Nre electrical imsta0etlon d� hare6i on tlre dffies sta�:
Foa o�ricE use oN�r
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"�"" Rough-in Ins on R uired7 ❑Yes
pecU eq ��o Inspection Other Thah Rough-In: 0 Ready Now,� Cap
%`��`� 1� You must mll the inspector when readyl Date Ready.
I certify that I am the �;LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspe�ion of the eledrical work at
Job Site Street Addr�s Ciry
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TownsMp Section Range Fire No. Cowty
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OwnedOxuPant Weme Please Provide Two (2) Phorre Num�rs Includirtg Area Code
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ElecMcal Utllity Electrical Utility Addr�s
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Cantracror / Company Name Contrador Licerrse Number Master Electridan or Power Lfmited Techniclan
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Mafling Addr�s (CoMracbor, Company or Owner Performing InstallaUon)
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Authorfaed Stgnature (Contrador or r PertortNrtg InstaDation) Please Provide Two (2) Phorre Numbers Inctudirrc,� Area Code
� (�ar.z)�6d -�� (7103) �'3-�fo%7
MSTRUCTIONS ON BACK OF YELLOW COPY i Rl1SRfll1F FI FCIAiCT/ Cl1PV �o �.,. ,� e, �«..