P - 76460REQUEST FOR ELECTRICAL INSPECTION �
1� 1 O�- 9 4 3 $ Minnesota Board of Electricity ��� �_ '
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �: :
(651) 642-0800 TTY/MRS 1-800-6273529 mwi+�.electricity.slate.mn.z�s
Describe -usinfl the back of the white copy if neces�s - the �vp�l�Lccuterg by ihi�s �e��uest; �. �. }_ r_ ,
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LNERAL FEES
IES
�0
'5
0
I CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
ADDITIONS TO THE GENERAL FEES
Y DWELLINGS (PER UNIT)
Boom a
ark Lots
Outdoor Lighting Stand
Traffic Signai Standard
Supplemental Fee @ $
Transformers u� to 10 I
ONE 8 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 Ins ection Tn s $20
Investigative Fee
Reinspection Fee $20
TOTAL FEE ;_i 1 p:_� ��
(minimum total fee is $20)
THIS AREA FOR INSPECTOR IISE ONLY
I hereby ceRify that I insDected the electrical installation descnbed herein on the dates stated:
f���
al Inspection $30 per Hour exaiaeo;aenr�oorvtu uaie
Special Ins�ection @ $.3t per Mile
�TH�S INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Ial 1181 II Iil ll l� II IN II III � 81 II III �all I IIII
1787943$
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�, Date: II Rough-in Inspection Required? ❑ Yes �] No I Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
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' You must call the inspector when ready! Date Ready:
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1 ce�ify that I am the C�] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
rJob Site Street Address. -.... .-. .-. j CitY �- J� ��I._� ''( 'i i4 �1 �f''-': s a�
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Section I Range I, Fire No.
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Please Provide Two (2) Phone Numbers Including Area Code
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! EIBCtryGal UtHitx ' tlectrical UtlGty AtltlreSS
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� Cpntractor / Company Name Contractor License Number Master Electrician or Power Limited Techni�
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Marimg Addres��Co�Vactor, Company or Owner Performinjq Installation;
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i Aut �zvd 3� naturo (Contractor or Owner Periorming Installation) � , Please Provide Two (2) Phone Numbers Including Area Code
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