P - 77434REQUEST FOR ELECTRICAL INSPECTION
1 s C�� � O� O � Minnesota Board of Electricity -
�� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.e[ectricity.state.mn.us
❑ NEW ❑ REMODEL ❑ ADDITION fjE�AIR Describe -using the back of the white copy'rf necessary - the work covered by this request:
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or aratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @ E50 Per Unil
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
h6n Retrofit a.25 er Fixture
Center Pivot Irrioation Boom � $40
I IIII II III II III II II! II III II III II III II III II III I lill
15730104
Tra(fic Sign� Standard
Suoolement� Fee � E
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
( TOTAL FE ) I � �`$ I
minimum total fee is $20 r�
iHISAqEAFqik6PECTORIAEM
I hereby ceNfy tl� I inspec�d the electrical instatla6on deuribed herei� on the dates sfa0ed:
—�
IECTED IF NOT COMPLETED WITHIN 12 MONTHS I
�Q� /e�:,- /� Rough�n Inspection Required'? ❑ Yes �7NO Inspedion Olher Than RougMn: ❑Ready Now �.Y�II Call
p- Ll/ V�'J You must call tF�e inspeclor when ready! Date Ready.
I certify that I am the LICENSED CONTRACTOR OCOMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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