P - 78466REC.�' EST FOR ELECTRICAL INSPECTION
1� 5 3�- 0 3 6� 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 .QRE ODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the xrork covered by this request:
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FEES
I
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Outdaor Lighting Standard � $1
ONE 8 TWO FAMILY DWELLIN6S, EACH UNIT
Includes the Service andlor Power Supply up ►0 500 Amperes, NI
Cirouits and Two Inspection Trips Each Dwelling Unit �$60
.LINGS PER UNI TOTAL FEE
550 Pe� Unit (minimum total fee is $20)
U�k $25 Twsa�nFOaKSrecronusEaav
� I hereby cerA(y lhat I inspecOed the ele�trical installaUon dexribed herein an Me daBes sl�ed:
OTHER ADDITIONAL FEES K�� � C o'r'°3
Pivot imgalioi
�clured Home
tional Vehicle
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Request Date: Roughin Inspectiai Required? ❑ Yes �NO Inspedion Other Than Rough-In: �Ready Nary �Will Ca�l
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You musl call the inspeclor when ready! Date Ready.
I certify that I am U�e�'CICENSED CONTRACTOR ❑COW�ANY ❑ OWNER and hereby req�st inspection of the elecfical work at: