P - 76619C REQUEST FOR ELECTRICAL INSPECTION
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I �� 9 9 9�' �� J � Minnesota Board of Electricity �- :
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �.`
(651)642-0800TTYIMRS 1-800-627-3529 www.electricity.state.mn.us
Describe -usin the back of the white copy 'rf necessary - the work co ed by this req st:
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„ � NERAL FEES Outdoor iahtino Standard (�D S1
✓ICES / POWER
0 to 400 Amcere
ALARM, COMMUNICATION, REMOTE CANTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus a$.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units C� $50 Per Unit
l�hting Retrofit @ $.25 per Fi�ure
Center Pivot Irrigation Boom @ $4C
Manufactured Home Park Lots l� $
Traffic Si nal Standard a$5
Su lemental Fee a $20
Transtormers u to 10 KVA a$10
Transformers over 10 KVA $ 20
Transfortner / Power Su I for Si ns / Outline Li htin $5
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
Addi[ional Ins ection Tri s a$20
Investi ative Fee
Reins ection Fee a $20
TOTALFEE �
(minimum total fee is $20) Z � -
I hereby certify that I inspected the electrical installaGon described herein on ihe dates stated:
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rough-in I Required? ❑ Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call
You must call the inspector when ready! Date Ready:
I certify that I am the p LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elechical work at
Job Ske Slreet Add^res/s� 1 / �
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_INSTRUCTIONS ON
Name -Please f
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Electrical Utility Address � ��
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� _,_ _ OARD OF ELECTRICIN COPY
Jumbers InGuding Area
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�Master Electrician ar Power
License Number
Two (2) Phone Numbers Including Area Code
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EB-OOOOtA-15 8.1.2004