P - 77641REQUEST FOR ELECTRI AL INSPECTION �'-�
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1- 8 51. _ o�� � Minnesota Board of Electricity ���� ���� � ����'��
� 1821 University Avenue Suite S-128�S�int au , Minn 1
(651)642-0800TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us ��'�
Describe -usin e back of the white py if necessary - the work covered by this request:
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GENERAL EES Outdoor Li hting Standard a$1
401 to 800 Am n
Above 800 Am r
CIRCUITS I FEEDERS
0 to 200 Amcere (
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus a$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units na $50 Per Unit
Center Pivot Irrigation Boom
Manufactured Home Park Lc
Traffic Si nal Standard a$5
Su plemental Fee a $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns I Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ection Tri s � $20
Investi ative Fee
Reins ection Fee a $20
TOTAL FEE
(minimum total fee is $201 �/
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I herebvi certifv ihat I insoected the electrical installation desaibed herein on the dates stated: I
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S' I Ins $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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I IIII II III II I�I I) III II III II III II II� II �II
1851045
Date: Rough-in Inspection Required? ❑Yes No Inspectian OtherThan Raugh-In: Ready Now ❑Will Call
� �/d� You must call the inspector when ready! Date Ready:
I certify that I am th LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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Township Section Range Fire No. Co�nty
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er/Oaxipant Name Please Pro�ride Two (2) Phone Numbers Including Area Code
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Electrical UUlitv Electrical Utildv Address
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iing lnstallador� � �
�r or Owner Pertortning Installation)
OF YELLOW COPY BOARD OF ELECTRICITY COPY
er Master Eleckidan or Power Limitetl Technician
License Number /��„�O / �
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ovide Two (2) Phone Numbers Including Area Code
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EBOOOOtA-15 8.1.2004