P - 79309� REQUEST FOR ELECTRICAL INSPECTION
�� - 7 7 3- 5 6 9 � Minnesota Board of Electriciry -
1621 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTYIMRS 1-800-627-3529 www.electricity.state.mn.us
C�} NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoor Lighting Standard @$1
Fee @ ;
uptol0
aver 10
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, Ail
Circuits and Two Inspection ?rips Each Dwelling Unit @$80
CIRCUITS OF LESS THAN 50 VOLTS
3 to �2 Uni� @$5o Per Unit (minimum total fee is $20) � �lU.DU
E2Ch Additi0nel U�it @$25 r�ns u�n Fae rcaeccrae usE orar
. I hereby certify Mat I inspected the electrical instaNation tlescribed herein on the dales sfaled:
OTHERADDITIONALFEES �G (�_����/
I inhtinn RPkofit G� 3 �5 ner Fiuture � r
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Request Date: Roughin Inspection Required? ❑ Yes Inspedion Othw Than Rough-In: dy Now � WiN Call
� jf j0lC� You must call the inspector when ready! Date Ready:
I ceRity that I am the C�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby iequest inspection of the electrical work at:
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