P - 788821-621-342 �
❑ REMODEL ❑
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of ElecVicity -
1821 University Avenue Suite S-128, Sairrt Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
2 Describe -using the back of ihe white copy 'rf necessary - the work covered by this request:
� Above 200 Ampere �Z10 �
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or y.50
ADDITIONS TO THE GENERAL FEES
Per Unit
I Transfamer I Power SuDDIy for Signs / Outline Lighting $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service aridlor Power Supply up to 500 Amperes, All
Grcuits and Two Inspection Trips Each Dwelling Unit �$80
�y TOTAL FEE
�nimum total fee is $20) 3�' S�
- _ nasMF/.wtrSPECTatuSEOKr
I hereby certfy tlwt I inspecBed Ihe dedrical insta6adon described herein on the daks staEed:
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF
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Request Date: Rough-in Inspection Repuired? ❑ Yes Inspection Other Than RougMn�y Now � Witl Call
� � —� You must call Me inspecta when r�dyl p�e �y;
I ceAify tliat I am the �ICENSED CONTRACTOR � CONPANY ❑ OYVNER and hereby request inspection � tlie electrical wak at:
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Job Site Address (SVeeL Baoc. a Route No.) ��e
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or
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Mester Eledridan a Power L'ani0ed Tednicien
License I�Munber
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� � . E8-00001A-14 8A.200Q