P - 75856������ 6 9� REQUEST FOR ELEC� RICAL INSPECTION
Minnesota Board of Electric
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
/���(� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.stale.mn.us
Descn'be -using e back of the white copy if n�essary - the work cover� by this requ�t:
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GENERAL FEES Outd�r LigMing Standard $1
SERVICES / POWER SUPPLIES Tra�c Sfanal Standard (iil $5
Above 2�0 Am ere �$10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGI
CIRCUITS, CIRCURS OF LESS THAN 50 VOLTS
Each S m Devi� or ratus @$.50
ADDRIONS TO THE GENERAL FEES
MULTIFAMILY DVNELLINGS PER UNI
3 to 12 Unifs @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDRIONAL FEES
Liphtkm Retrofit an $.25 oer Fbdure
VSTALLATIOPI MAY BE ORQERED
IIIII IIIII (IIII IIIII I�III IIIII ull) IIII) �� I�
_ 19426691
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ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Indudes the Service andlor Power Supply up to 500 Amperes, M
Circuiis and Two Ins�on Trips Each Dwelling Unit @$80
Addidonal Irus�on Trios Co9 $20
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total fee is $20) a'`�
I herebY �ertltY � I inspeded tha el�trfcal InsleOetlon desalbed Y�eretri on the dat� s�ted: i
VIPLETED WITHIN 12 MONTHS
FOR OFFICE USE ONLY
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�' Rou h-in Ins
g pecUon Required? ❑ Yes �1 o I�pectlon Other Than Rough-In: ❑ Ready Now�lm Cell
a� 3-� You must cell the inspedor when readyl �te Ready.
I certify that I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby r�uest inspection of the electrical work at
Job SiOe Slreet Addresv �y
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Moke. MN
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�1 UHqty Addra9s
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Contractor Licerrse Number Master Electriclan or P�
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�InstaOatlon)
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