P - 784431-507-679 7�
❑ NEW 0 REMODEL ❑ ADDITION
401 ta 800
Above 800
,UITS / FEE
0 to 200 Ar
Above 200
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each AddiGonal Unit @ $25
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IIII �I II� II (I) II (�I (I III II (II II I�I II III �� I�I
15076797
REQUEST FOR ELECT CAL INSPECTION
Minnesota Board of Electricity ��� � � ��,,i�� -
1821 University Avenue Suite S-128, Saint Pa�innesota 5510�
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
R Describe,using the back of the white copy if necessary - the work covered by this request:
Standard
m
Transformers over 10 KVA $ 20
Transfortner / Power SuDPIy for Signs I OuUine LighGng @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
Additional Inspec6on Trips � $20
InvesGaative Fee
(minimum total fee is $20) � ��
TH5 RPFA FOR INSPECTpt USE OKv
I hereby cerdFj tl�al I inspecfed the electrical instaNa6on desaibed heran on Ihe daBes sta�d:
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Kequest uate: Rough-in Inspection Required? LJ Ves (�� Inspection O[her Than Rough-In�Ready Now ❑ WNI Call
�}� �"�� You must call the inspeclor when ready! Date Ready:
I certify that 1 am the �CENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elecfical work at:
�na�rtw��c�nsunewcn�r�eLL�mrcorr noqKOOrELECt�ci�rcvrr tu�uwiw-ia e.i.cure