P - 78162REQUEST FOR ELECTRICAL INSPECTION
1� 5 5=0 �� O o � Minnesota Board of Electriaty
1821 University Avenue Suke S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electriciry.state.mn.us
NEW REMODEL ❑ ADDITION ❑ REPAIR Describe -using the k of white cop 'rf necessary - the work covered by qis request:
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ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or ratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units � a50 Per Unit
Each Additional Unit � a25
OTHER ADDITIONAL F
LiqhGnn Retrofit �$.25 oer Fixture . �
Supplemental Fee @ ;
Transfortners up to 10
Tr�sfomiers over 10
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Txro Inspection Trips Each Dwelling Unit @$80
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(minimum total fee is $20) � �'�S D
THIS MEA FOR WSPECTpi USE 011Y
I hereby cerUfy that I inspecled the elecbical instaHa6on described herein on the dafes sta�d:
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Ilul IIIII IIIII Illh II�I II"! II�I IIlII N�I II�
155080�5
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Request Date: Rough-in Inspection Required? ❑ Yes No Inspedion Other Than Rough-In: Ready Now ❑ Will Call
—�, — O � You must call the inspector when ready! Date Ready:
I certify tl�at I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Jab SRe Address (Stree4 BoX or Route No.) CiH Zip Code
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Section Township Range ire No.
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ower Supplier� �
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Owner � ing Instauaiion) � `
iy Owner Perfortning Installation)
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BOARD OF ELECTRICITV COPV
Please Provide Two (2) Phone Number(s) Indudirg Area Code
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ise Number Master EJectri 'an or P Limtted Technician
. �. . / License Number
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E8-OOOOtA-14 8.1.2002