P - 75798[� REQUEST FOR ELECTRICAL INSPECTION ;�
I �� v� 0� 4 51 � Minnesota Board of Electricity
1 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
I Describe -using the back of the whfte copy 'rf n� -�e work cov_ered �y this �+".,;�,
' I SERVICES
' 0 to 200 Ampere @ $5
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S m bevice or A @$.50
ADDITIONS TO THE GENERAL I
3 to 12 Units
Home
Fee
ONE $ TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, Ad
Circuits and Two Ins�Ction Tdps Eadi Dwelling Unit (� $80
Add(tional Ins on Td $20
Investlgative Fee
Reins 'on Fee $20
TOTALFEE
(minimum total fee is $20) � �
rws u�a wa ws�c�� usE ora.r
I hereby crertdfy tlmt I ir�speded tlre elechipl insiepa8nn dascn'bed hereN on fhe dales sfeted:
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5 al Ins on $.31 r Mile
_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
FC�R UFF'sCE USE OP4Lr
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��' Rough-in Inspectlon Required9 Yes ❑ No Inspection Other Than Raugh-In: Ready Now OWitl CaU
You muet call the inspedor when readyl Date Ready:
I certdy that I am the 0 LICENSED CONTRACTOR ❑ COMPANY OWNER and hereby request inspection of the electri work at
Job Re Street Address �
� � ��� c�����
com�r
or
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Niunber Master �ectridan or
Licen� Number
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