P - 78981REQUEST FOR ELECTRICAL INSPECTION
1� 6 6 5� H J O � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW ❑ REMODEL ❑ ION ❑ REPAI cribe -using the bxk of the white copy if necessary - the work covered by this request:
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JICES / POWER SUPPLIES
0 to 400 Ampere @ $25
40110 800 Amcere � S50
�M, COMMUNICATION, REMOTE CONTROL, SIGNALING
;UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus �$.50
ADDITIONS TO THE GENERAL FEES
iIFAMILY DWELLINGS PER UNI
3 to 12 Units �$50 Per Unit
Each Additional Unit @ $25
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L6658502
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspec6on Trips Each Dwelling Unit �$BO
Additional Inspec6on Trips � $20
InvesSaaGve Fee
TOTAL FEE � �
(minimum total fee is $20) �' �✓ ; Z
iH15 ARER FOR INSPECTOR USE plv
I by that I irtspected the elec4ic� ins411�on bed herein on tl�e d�es staled:
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2 _�-o
DATE
12 MONTHS
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�� I�9hi� �RS�Ction ReQuired? � Yes ❑ No InsPection Olher Then RcwgMn: OReady Wow ❑ VWI Call
1 Y�'� You must call the inspector when ready� pate R�y
I cefify �at I am tt�e �.LICENSED CONTRACTOR q COMPANY p OWNER and hereby request inspec�on of �¢�� �� �:
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