P - 76614REQUEST FOR ELECTRICAL INSPECTION ��`�
1� 813 �� J 1 � Minnesota Board of Electricity ��
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
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(651) 642-0800 TTY/MRS 1-800-6273529 www.electricity.state.mn.us
Describe -using the back of the ite copy if necessary - the work covered by this request:
�1'1 FS I1 � t�'1 9' 'a �\ (p
� "GENERAL FEES Outdoor Lighti Standard @ $1
SERVICES I POWER SUPPLIES Traffic Si nal Standard @$5
0 to 400 Amcere (�a $25 Su plemental Fee a$20
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus (� $.50
@
Lighting Retrofd @ $.25 per Fixture
Center Pivot Irrigation Boom @ $4(
ManuFactured Home Park Lots an S
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / Outline Li htin $5
ONE 8 TWO fAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circeits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ection Tri s a$20
Investigative Fee
Reins ection Fee a $20
TOTAL FEE
(minimum total fee is $201
I inspected the electrical installation described herein on the dates staled: �
Se arate Bondin Ins ection $20 `� `� ( L-��� F'
S 181 If1S eCtiOn $30 p2f HOU� E%PiReoinennoor+eo onTe
Speciai Ins ion $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rough-in Inspection Required? ❑Yes�1Jo Inspection OtherThan Rough-In: 0 Ready Now ilI Call
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You must call the inspector when ready! Date Ready:
I certify that I am the �LICENSED CONTRACTOR O COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Si[e Street Address �i�y
Rc �_�.. rr,IticQ n__ A �/� r. I/
Owner/Occupant Name( �`Jt� �, _ �
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Eledrical Utiliry Electrical Utilfty Address
Contractor / Company Name G
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Mailing Address ontrador, Company or Owner Perfo g Installation)
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Authoriz ign ure (Contractor or Owner Perfortning Installation)
INSTRU 10 ON BACK OF YEL O OPV R(lARfl nF FI Ft`T
Fire No. County - a
Please Provide Two (2) Phone Numbers
l`a%3).S'7! 77�9 � )
Plea�
(k�s) w.�
Master Electrician or
License Number
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