P - 78214REQUEST FOR ELECTRICAL INSPECTION
1� 5 3 Cl. - 4 9 6❑7 Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Min�sota 55104
- (651) 642-0800 TTY/MRS 1-800-6273529 www.electricity.state.mn.us
NEW O REMODEL 0 ADDITION REPAIR Describe -using the back of the white copy 'rf necessary - the work covered by this request:
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SERVICES I POWER
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Eaoh System Device or Apparatus �$.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighting Rehofit @ $.25 per Fixture
Cenfer Pivot Irrioation Boom � S40
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Transfortners u to 10 KVA $10
Transfortners over 10 KVA $ 20
Trans(ortner / Power Su I for Si ns i Outline Li hGn $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNtT
Includes the Senice and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each 0welling Unit @$80
Additional Ins tion Tri $20
Investi ative Fee
Reins tion Fee $20
TOTALFEE
(minimum total fee is $20) � �
rws � F«e iraaECrors use
I hereby cer6y that I inspected the electrical installa6on described herein on the dates stated:
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Ir.71ALLAl IV1\ MAT 6C VKUCKtU UI,I�UNIVtC:I tD IF NOT GOMPLETED WITHIN 12 MONTHS �
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' Rough-in Inspection Required? ❑ Yes No Inspedion Other Than Rough-Irr. Ready Now ❑ Will Call
You must call the inspecta when ready! Date Ready:
at I a the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elecirical work at:
�dress (Street. Box, or Route No.) City Zip Code
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Cantractor / Company Name
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Mai ng dress (Contractor, Company or
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Auth ' ig ture (Cantra pai
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Installation)
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BOARD OF ELECTRICITV COPY
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License Number
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