P - 76488,���
REQUEST FOR ELECTRICAL INS.PE T ON �� �� ��
2 i o� V� 3 3 6� Minnesota Board of Electricity ���%,�1 k �
1821 University Avenue Suite S-128, Sai t aul, ut�%sota 55104 �y.
(651)642-0800TTY/MRS 1-800-627-3529 wxtiv.electricity.sta�e.mn.us ��!;��
Describe -using the back of the white copy if necessa the work wvered by this request:
GENERAL FEES Outdoor Lighf Standard @$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere na. $25 Supplemental Fee @$20
UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL
fIFAMILY DWELLINGS (PER UNI�
3 to 12 Units CaD $50 Per Unit
Center Pivot Irrigation Boom @
Manufactured Home Park Lots (
Recreational Vehicle Park Sftes
INSTALLATION MAY BE ORDERED I
I IEN II III II'�I � IE� �i ill II III II I II II III N� I�If
? 0 7 8 3 3 6 1
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 Inspection Trips @ $20
Investiaative Fee
TOTALFEE I � /�. ��
(minimum total fee is $20) (.�
I hereby certiry that I inspeded ihe electripl installation desaibed herein on the dates slated: �
:. �G�
'ED IF NOT COMPLETED WITHIN 12 MONTHS __ ___ _�
�,1����-��� `3�
Date: Rough-in Inspection Required? ❑Yes �No Inspedion OtherThan Rough-In: ❑ Ready Now �/ili Call
I�"f`' '�' t/�� You must call the inspector when ready! Date Ready:
I certify that I am the L�I�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site SVeet Address �_/ City
r.t /I i ' �/�l U �
/V
Township Section Range Fire No. County
Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
r %C.h �-iz� (7� 5`l I -lo(� k'� ((�( � lo ��=8S7�o
Electrical ity Eledrical Utildy Address
actor, Gompany or
��� E
(Contractor or Owi
Contrador License Number Master Electncian or Power Llmdetl Techni�
�; ,� O�� License Number
i
r t—i
g Installation)
��� ���_
stallation) Please Pro e Two (2) Phone Numbers Including Area Code
i'o�//-{��� \ /