P - 76215REQUEST FOR ELECTRIGAL INSPECTION
L� o V�� 6�� � Minnesota Board of Electricity
1821 University Avenue Suite S-1 Z8, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-500-627-3529 www.edectricity.state.mn.us
Desaibe -using the bagk ofthe white copy'rf necessary - e work covered by this requ�t:
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GENERAL FEES Outdoor Lighting Standard @$1
SERVICES / POWER SUPPLIES Trafic Siqtmial Standard (a� $5
:UITS / FEEDERS
0 to 200 Ampere @ $5
Above 200 Ampere @$10
2M, COMMUNICATION, REMOTE CONTROL, SIGNALING
;UITS, CIRCURS OF LESS THAN 50 VOLTS
MULTIFAMILY DWELLINGS PEI
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
FEES
IIII II I� � W� UI 11I� II �I II III II I� U� I�
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ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Twro Inspea.fion Trips Each Dwelling Unit @$80
Addfional Ins on Td $20
Inv�gative Fee
Reinsp�tion Fee $20
TOTAL FEE
(minimum total fee is $20) �� - �
7HISAREAFOR W9PECi0R USE 0�4Y
I hereby ceNfy thai I G�d the electrical 6�te0atlnn d� herein on tlre dates ateted:
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F6R OFFiCE ilSE ONiY
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��� Rough-In Inspectlon Requhed7 �Yes ❑ No Inspecdon Other Then Rough-In: ,�'lieady Now � WiA Call
, � I� � �i �p You must ce0 the hispector xrhen readyl Da[e Ready.
I certify that I am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
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ejny or Owner PerformU�g Installatlon)
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or Owner Perfortninp I�tailatlon)
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vlde Two (2) Phorre Numbers Incli
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acror ucer�se rvumner master t�eartdan or rower umttea
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