P - 78405REQUEST FOR ELECTRICAL INSPECTION
1� t�, g 0�� 0 1 � Minnesota Board of Electricity -
r 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 ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by lhis request:
GENERAL
SERVICES /
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aouaratus � 5.50
MULTIFAMILY
3�12 Ui
LighGng Retrofit
Cenler Pivot Irrii
Outdoor Liahtina Standard
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes tl�e Service andlw Power Supply up to 500 Amperes, All
Grcuits and Two Inspection Trips Each Dwelling Unit �$60
Additional Inspection Trips � $20
Inves6aative Fee
TOTALFEE
(minimum total fee is $20) � 2.�.��
TM$ MFA Fpt INSPECTq1115E OKY
I hereby ceray that I inspected Ihe electrical insfallation described 1� on Ihe da0es sta�d:
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Request D: Rpugh-in Inspectlon Required? ❑ Yes Inspedion Other Than Rough-I y Now ❑ VWI Call
��� V/� You must call the inspecta when ready! Date Ready. . � �jl �
I cerMy that I am the ❑ LICENSED CONTRACTOR ❑COMPANY ❑ OWNER and heieby request inspection of the electrical wak at: