P - 75937REQUEST FOR ELECTRICAL INSPECTION `
1 s� 9� m 2�� � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.slate.mn.us
�°LSing�the back o,�thgwhite copy if nec�ssary�ge work crover� by this request: _
Above 200 Ampere tLil$10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCURS OF LESS THAN 50 VOLTS
Each S m Device or $.50
ADDITIONS TO THE GENERAL FEES
2 Units @ $50 Per Unft
Addfional Unft � $25
r�T.
�
BE ORDERED
Stamddard
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includas the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Ir�specUon Trips Each DwelGr�g Unit �$80
Addftiomal I�pection Trips @ $20
Inv�stiaative Fee
TOTAL FEE .tj�
total fee is $20) , � ! �«
� herBbY cer�Ytlrat I ins�ted tlre electrical ireta0afion desaibed herein on 6re dat� atefed: I
72 MONTHS
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�' Rough-in Inspecdon Requhed? ❑ Yes o I
� rtspecUon Other Than Rough-In: ❑ Ready N NV� Ca8
You must call the Inspector when readyl Date Ready:
f certify that the I'�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection af the electric�al work at
or
�or r�se rvumber maste7' EIeCtrldan or PowB� L
��'/�ra /� 6 Ucense Number
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BACK O OYV COPY BOARD OF ELECTRICT' COPY FR-OMIAIA-1F x 1 7fma