P - 75945REQUEST FOR ELECTRICAL INSPECTION
1������� V� 8'29 University A n e S�'��te S- 28, Saint Paul, Minnesota 55104
(651) 642-0800 TlYlMRS 1-800-627-3529 www.electricity.state.mn.us
Descrtbe -using the back of the white copy'rf necessary - the work covered by this request:
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0 to 200 Am re $5
Above 200 Ampere @$10
tM, COMMUNICATION, REMOTE CONTROL, SIGNALING
,UITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Unfts @$50 Per
Each Additlonal Unft @ 9
Fbchue
Hour
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19003284
Traffic
Includes the Servit� andlor Power Suppty up to 500 Amperes, All
Circuits and Taro Insp�on Trips Each Dwalling Unit @$80
AddiUonal Ins�ctian Trips @ $20
Irnestlaative F�
TOTALFEE ��
total fee is $20)
I hereby certlfy th� I inapeded the elechical instaVadon d�d hereN on the dates stated:
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:CTED IF NOT COMPLETED WITHIN 12 MONTHS
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��� Rough-in Inspection Required? �❑ No Inspectton Other Than Rough-In: ❑ Ready Now 0 WIII CeII
��°� S You must call the inspector when ready! Date Ready.
I certify that I am the��CENSED CONTRACTOR � COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Addr�s Ciry
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W�e (Con o r Perfortning Installation) Please Provide
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Mas[er Electridan or Power
Li�r�se N�nnber
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