P - 78824REQUEST FOR ELECTRICAL INSPECTION
1� 4 4 6� V�� � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
NEW ❑ REMODEL ❑ ADD� ON/ AREPAIR Describe -using the back of the white copy'rf necessary - the woric covered by this request:
SERVICES
0 to 4(
401to
GENERAL
IMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS OF LESS THAN 50 VOLTS
>ystem Device or Appazatus � 5.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units �1$50 Pe
Each Additional Unit �
Mile
1Y BE ORDI
��I�I �III� IIIII IIIII �III4I�III II�II IIIII �NI �Ifl'
Outdoor
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Pmwer Supply up to 500 Amperes, NI
Cirouits and Two Inspection Trips Exh Dwelling Unit � S80
Additional Inspection Trips $2(I
Investiaative Fee
TOTALFEE y�
(minimum total fee is $20) p" C�• Sn
TH6 N2EA FIXt IMW ECTOR IEE pLV
I hereby cer6y tl� I inspecBed tlie electrical insfall�on des�ed here� an Ihe dales st�ed:
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14466221 l (p�� Q
. � 3 �p,5
ReQuest Date: Roughin Inspecfion Required? ❑ Yes No Ins
P�� Other TTian Rough-In: Now ❑ WiN Call
— d 3 You must call the inspedor whe� readyl pete Re�y .
I certiy ihat I am tl�e LICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of the electrica� wak at;
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