P - 77686q REQUEST FOR ELECTRICA INSPECTION �
1����- 4 9 3� Minnesota Board of Electricity �,� � �- :
1821 University Avenue Suite S-128, Samt P�urMiM1ne����� �`
(651)642-0800TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy if necessary - the work covered by this request:
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ENERAL FE S Outdoor Lightin Standard $1
SERVICES I POWER SUPPLIES Traffic Si nal Standard $5
0►0 400 AfI1D8f@ (D ��Y "� (;�. � Sunnlemental Fee rni R70
ALARM, COMMUNICATION, REMOTE CONTROL, SIGi
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or A aratus a$.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL
Lighting Retrofit @ $25 per Fixture
Center Pivot Irrioation Boom an $40
Special Inspection @ $30 er Hour
S cial Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED
IIIII IIIII111i1 IIIII Illil IIEII IIIrI IIIII U� I� �
1864493p
� Transformer I Power Supply for Signs I Outline Lightinq @$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circufts and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
investiqative Fee
TOTAL FEE
total fee is $20) � �-1 ` � `'
I hereby cerlify that I inspected ihe electrical installation desaibed herein on the dates stated: �
APLETED WITHIN 12
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"` Rough-in Inspection Required? �Yes ❑ No Inspection Other Than Rough-In: � Ready Now�Will Call
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l.j �% l(, �� You must call the inspectar when ready! Date Ready
I certify that I am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job SRe SVeet Address ��y
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tor / Company Name
Range Fire No. County ,
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Please Provide Two (2) Phone Numbers Incl
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Utility Address
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Mailing Address (Contractor, ompany or Owner Performing Installation)
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Authorized ' a ctor or Owner Performing Instailation)
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INST � CTIONS ON YELL COPV BOARD OF ELECTRICITY COPY
Master Eledrician or
License Number
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ise Provide�Two (2) Phone Numbers Including rea Code
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