P - 78615`7 REQU�ST FOR ELECTRICAL INSPECTION
1— 4, 1 0� 5 1 7 � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 T'fY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW ❑ REMODEL O ADDITION REPAIR Describe -using the back M the white copy if necessary - Me work covered by lhis request:
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CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units �$50 Per Unft
Each Addi6onal Unit � E25
Su lemental Fee 520
Transfamers u to 10 KVA E10
Transfamers rner 10 KVA S 20
Transformer / Power Su fw S' ns / Outline ' htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Ir�cludes the Service andla Power Supply up to 500 Amperes, Ali
Cirouits and Two Inspec6on Trips E2ch Dwelling Unit � S80
Investi ative Fce
FEES Reins tion Fce S20
TOTAL FEE .[�"�
(minimum tofal fee a $20) � � �� v
THS NiFA FptlLSPECTqi l6E MY
I hereby cer6Qy tliM I inapeded Ihe ekctrical insialaGOn de�ribed herein on the dales slaBed:
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. FOR O�F10E i38E t1NLY
11111 Iilll II III II III II lil II III II�N� N� 1�
14L05779
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Request Date: T Roughin Mspection Required? ❑ Yes � l�o Inspedion OIAer Than Rough-In: �dy Now ❑ NI� CaN
'''— (�� '- V3 You must call lhe inspeda when readyl pate Ready. . \
I certify lhat I am the �NSED CONTRACTOR ❑COMPANY ❑ OWNER and tiereby request ir�pection of the electrical work at: