P - 78472�
REQUEST FOR ELECTRICAL INSPECTION �
1°� 512 - 2 6 3� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
�,�. �ta� � � .._..:
(651) 642-0800 TfY/MRS 1-800�27-3529 www.electricity.state.mn.us
❑ NEW EMOq L❑ ADDITION REPAIR Describe -using the back of the white copy 'rf necessary - the work covered by this request:
i�.7C� �C���� � � 1 � � � �5
GENERAL FEES Outdoor Li htin Standard $1
SERVICES I POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Amcere �$25 Su eme�tal Fee $20
IMMUNICATION, REMOTE CONTROL,
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Apparffius @ $.50
ADDITIONS TO THE GENERAL F
3 to 12 Units
Unit @ $25
ALLA'
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1 5 1 2 2 6 3 3.
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
TOTAL FEE I b, c� O
(minimum total fee is $20) � �
TIMS RREA FIXt IlbPECTpY USE pdY
I hereby ceNy that I inspected tlie electrical install�on desdibed hwein on Me dates st�ed:
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Request Date: Rough-in Inspection Required? ❑ Yes � No Inspection Other Than Rough-In: ❑Ready Now �VYdI Call
�j — a q� 3 You must call the inspeda when ready! Oate R�dy:
I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of ihe electrical work at: