P - 77315REQUEST FOR ELECTRICAL INSPECTION �,����"F `^ �
1� V���- 3 2 3�Q Minnesota Board of Electricity � '��,
1821 Universit Avenue Suite S-128, Saint Paul, Minnesota 55104 �.
, (651) 64 /MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy if necessary - the work y this request: ��r�[`_ �Q
!�•'R- C�F�T- ou�t'c�i' �'
GENERAL FEES Outdoor Li hting Standard $t
SERVICES / POWER SUPPLIES Traffic Sional Standard an. $5
Above 800 Am ere a$75
CIRCUITS / FEEDERS
0 to 200 Am re $5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Liahtina Retrofit (c� $25 cer Fi�ure
�er Hour
per Mile
MAYI
IIII II III II I�i li ii� li III I! III II ill II III �� I�
18223230
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Addftional Inspection Trips @ $20
Investiaative Fee
TOTALFEE
D
total fee is $20) e?�% • �'
I inspected the electrical installation described herein on the dates stated: �
7
Date: Rough-in Inspection Required? ❑ Yes o Inspection Other Than Rough-In: eady Now �Will Call
�"+�S (/ S You must call the inspector when ready! Date Ready:
I certify that I am the.1� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Street Address � Ciry
58� l a 2�- iv.�� f'; d LEy
Township Sectlon Range Fire No. County
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Owner/Occupant Name Please Provide Two (2) Phone Numbers InGuding Area Code
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Elecirical Utility Electrical Utility Address
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any or Owner erfortning Installalion)
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or Owner Performing Installation) Please Provide Two (2) Phone Numbers Including Area (
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