P - 76559REQUEST FOR ELECTRICAL INSPECTION
1�� V�- 8 9 9 8❑ Minnesota Board of Electricity �!- _
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 wx�w.electricity.state.mn.us
Describe -using the back of the white copy if necessa the work covered by this re uest:
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I POWER SUPPLIES
to
Above 200 Am ere ,$10 �
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Apparatus C�a $.50
3 to 12 Units @$50 Per Unit
E2ch Additional Unit @ $25
OTHER ADDITIONAL FEES
Liqhtinq Retrofit (� $.25 per Fi#ure
Traffic Signal Standard
Supplemental Fee @ $
Transformers up to 10
Transformers over 10 h
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
Additional Inspection Trips @ $20
Investiqative fee
TOTALFEE I y'�vQ�
(minimum total fee is $20)
THIS AREA FOR INSPECTOR USE ONLV
that I inspected the electncal installation descnbed herein on the dales stated:
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ecial lnspection $30 per Hour t*��Kt� ^ePN°��t� oA,
edal Inspection a� $.31 per Mile
INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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L7818998
uace: � Rough-in Inspection Required? ❑ Yes 7� No I Inspection Other Than Rough-In: [�Ready Now ❑Will Call
f' �`,� �Q6 li, You must call the inspector when ready! I, Date Ready:
I ceRify that I am the L�] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER
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! Job Site Street Address � - � �-�
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I T w hip Sec[ion �� Range 1
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'� OwnedOccupant Name -
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,� Electrical Utility ��, Electrical Utility Address
', XGEL EE�EI;r,-Y '�
and hereby request inspection of the electrical work at:
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Please Provide Two (2) Phone Numbers Including Area
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�.. Contractor / Company Name j Contractor License Number Master Electrician or Power Limited Technician
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�� Mailing Address (Contractor, Company or Owner Performing Installation) - �
I�'�0{� Tl�:%�I70RI�1_ �:C3AI}, SA3�vT F'A�.�i_, Mh! �}`�114
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� Authorized Si naj�ontractor or Owner Performing Installation) ' Please Provide Two (2) Phone Numbers Including Area Code
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