P - 78745REQUEST FOR ELECTRICAL INSPECTION -
�-� 2 3� 0�� � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-OB00 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -usi th back of the white copy'rf necessary - the work covered by this request:
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SERVICES I PC
0 to 400 Ai
401 to B00
AIARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or ratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units (a� $50 Per Unit
Each AddiGonal Unit @ $25
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ONE & TWO FAMILY DWELLIN6S, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Exh Dwelling Unit �$80
(minimum total fee is $20) I pC �'��
TWSRPFAFdiHSPECtdiU5E0NLv
I hereby certiy tlul I inspected the elec6ical instaXakon descnbed her�n an Me d�s sta�:
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�50
Request Date: Roughin Inspection Required? ❑ Ves nspedion Other Than Rough-In: ❑Ready II Call
� � �('j � You must wll the inspector when ready! Date Ready:
i certify that I am the ❑ LICENSED CONTRACTOR ❑COIu�ANY ❑ OWNER and hereby riequest inspection of the electrical work at:
Job Site Address (Street, BoX or Route No.) Cily �p �e
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Section Township Range Fire No. n
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Nnpany Name �- Contra or Lic
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s(CoMractor, Company or rf rtning Installation)
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na oMra ompany or Owner Performing Installation)
pN K BOARD OF ELECTRICIT' COPY
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�i � � � License Number
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