P - 76291• F�EQU�ST FOR ELECTRICAL INSPECTION
1�� J�� 5 3 6 �❑8 Minnesota Board of Electricity _
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
' . (�51) 643-0800 TTY/MRS 1-800-627-3529 www.elecri-iciry.state.mn.us
Desctibe -using the back of the white copy'rf necessary - the work covered by this request:
L�CEL EhlE�i�G`t SR�1EF�'S �WTTCH
GENERAL FEES Outdoor Liahtina Standard na �1
�
i1�ARM, GOMMUNIGATION, REMOTE CANTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each 5ystem Device or Apparatus @$.50
� ADDITIONS TO THE GENERAL FEES
5 per Fixture
Boom no $4(
Hour
Traffic Signal Standard @ $5
Supplemental Fee @ $20
Transfortners u to 10 KVA a$10
Trensformers over 10 KVA $ 20
Transformer I Povrer Su pl for Si ns I Outline LI htln @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Suppiy up to 500 Amperes, All
CircuiGs and Two Inspection Trips Each Dwelling Unit @$80
Iherebycert(y
aaucH m
FWAL INSPECTION
�weoineumc
DISCONNECTED IF
Fee a $20
TOTALFEE
iimum total fee is $20) �8n �"d
the electrical instaliation described herein on tl�e dat� sfated:
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'LETED WITHIN 12 MONTHS
II�II��III��I�IIII�III�IIIII REC� JUN 1 �
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�' Rough-in Inspection Required? ❑Yes �]] No Inspec5on Other Than Rough-In: [�Ready Now OWill Call
+� ����d �� You must cail the Inspector when readyl Dete Ready:
I eertify that I am the � LICENSED CONIRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
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�n�uauvu:uparn rvame Please Provide Two (2) Phone Numbers IncWi
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Electripl Utility Electripl Utility Address
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Conhaotor / Company Name Contractor License Number Master Electrician or Power
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Meiling Aaldrpsa (Contractor, Company or Owner Perfortning Insfallation)
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Aptltorized Signature (Contrac[or or Ovmer Performing Installation) Please Provide Two (2) Phone Numbers IncWc
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WSTRUCTIONS ON ACK OF YEILOW COPY RC1ARIl f1F FI FCTAIRITV CnPV �e .