P - 79022'7 REQUEST FOR ELECTRICAL INSPECTION
1- � 01 � 1� O � Minnesota Board of Electricity -
� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
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❑ NEW ❑ REMODEL ❑ ADDITION 0 R AIR Describe -using the back of the white copy if necessary - the work covered by this request:
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GENERAL FEE Outdoor Li htin Standard $1
SERVICES / POWER SUPPLIES Traific Sianal Standard (� $5
401 to 800 Am re $50
Above S00 Am re $75
CIRCUITS I FEEDERS
0 to 200 Am re $5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Exh Svstem Device or Aooaratus �$.50
3 to 12 Units @$50 Per
Exh Additional Unit � ;
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspec6on Trips Each Dwelling Unit �$80
TOTAL FEE I +�
(minimum total fee is $20) �< <
iH5 ARFA FCR TSPELTOR USE OI�IY
I hereby certify Mat I inspetted the elettrical instapation described hwein on the daRes staBad:
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I certify that i am tt�e
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Rough-in Inspection Required? ❑ Yes No Inspedion pthet Than Rougli-In: ❑Ready Now I Call
You must call the inspector when reatly! pe(e R�dy,
�ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical wak at:
or Roule No.j CitY ZP Code
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ConV 'cense N�xnber Mester Eledridan a Power ited Technician
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