P - 776505 REQUEST FOR ELECTRICAL INSPECTION
�— 7��� 7 0 8 ❑ Minnesota Board of Electricity -
1821 University Avenue Suite 5-128, SaiM Paul, Minnesota 55104
(651) 642-0800 TlY/MRS 1-800�27-3529 www.electricity.state.mn.us
❑ NEW O REMODEL�O ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
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tM, COMM ICAI`IAN; R€AfOTE GUNTROL, SIGNALING
UITS, CIRC ITS Of LESS.Ik#N 50 VOLTS
Each System Device or Apparatus @$.50
ADDIT�ONS TO THE GENERAL FEES
fIFAMILY DWELLINGS PER UNIT
3 to 12 Units �$50 Per Unit
Each AddiGonal Unit � $25
OTHER ADDITIONAL FEES
Retrofit � $.25 oer Fixture
r�affic
Fee
Includes lhe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
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(minimum total fee is $20) s ,SC/
iM15 AREF FOR INSPECTOR USE IXdY
I hereby cer6fy that I inspected the electrical installa6on described herein on the dates sfa0ed:
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tion $.31 r Mile
1LLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Request Date: Rough-in Inspection Required? ❑ Yes Inspedion Other Than Rough-In: ❑Ready Now Will Call
-� ��� G� S You must call the inspecta when ready! Date Ready:
I certify that I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
�na�uuc��ons aN ewcR vF �ELLOw cvP7 BOAIiD OF ELECTRICITV COPV EB•OOOOtA-14 8.1. 2002
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