P - 782571-44�-287 �
❑ NEW ❑ REMODEL ❑ ADDITION �
2 � �k Ca+ i�•
GENERALFEES
SERVICES I POWER SUPPLIES
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
Boom
Hour
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TlY/MRS 1-800-627-3529 www.electriciry.state.mn.us
� Describe -using the back of the white copy if necessary - the work covered by this request
'--t/� �./` !Iti- w � V �/U�� �. �
Outdoor Li htin tandard $1
Traffic Sianal Standard � E5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes tt�e Service andlor Power Supply up to 500 Amperes, All
Cirouits and Two Inspection Trips Each Dwelling Unil @$BO
( TOTAL FE; I �� /� 5)
minimum total fee is $20 F�•
TNIS AREA FIXt INSPECiOR USE ONLV
I hereby certiry Mat I inspected the elec6ical installa6on described herein on tlie dates sfaled:
r
i ii�� o �u ii ��� �� i�i �i ii� ii iit �i �i� �i �i� n �n ��
�� a�St
1 4 4 1 2 8 7�9 :�;-�� �"��10 oZ
�" S�
Request D te: Rough-in Inspection Required? ❑ Yes No Inspedian Other Than Rough-In: eady Now ❑ Will Call
8/�� You must call the inspecta when ready! Date Ready:
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at::