P - 79210REQUEST FOR ELECTRICAL INSPECTION
1` 1 U C3 - 5 3 2� Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-08Q0 TTYlMRS 1-800-627-3529 www.electricity.state.mn.us
0 NEW � REMODEL O ADDIjIQf���O�P��„j�e,scpbg;y�r�� t�l�pf.jt��,p�fr ite copy if necessary - the wo�k covered by this request:
0 to 400
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
GRCUlTS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aratus $.50
ADDITIONS TO THE GENER4L FEES
3 to 12 Units @$50 Per.Unit
Each Additional Unit @ $25
Outdoor Liahtinq Siandard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
(minimum total fee is $20) I 2�•$0
iH15 MFA FOR INSPECTqY USE OILY
I hereby certify that I inspected the electrical installa6on descnbed herein on the dates sta�d:
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Request Date: Rpugh-in Inspection Required? Yes ❑ Ins
pedion Other Than Rough-In: ❑ dy Now � Vvll Call
����4 You must call the inspecta when ready! Date Ready:
I certify that I am the �10ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of fhe elecfical work at:
INSTRUCTONB ON BACK OF VELLOW COPY BOARD OF ELECTRICRV COPY EB-OOOOtA•14 8.1. 2002 �