P - 76415REQUEST FOR ELECTRICAL INSPECTION
1 2 9 7 4 3 8 Minnesota Board of Electriciry
� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 =
www. electrici ty. state. mn. us
Identity the work covered by this request: � h ,L e � � u SL
❑NEW REMODEL ❑ADDITION ❑REPAIR C��C� /� ��� w/ �� � �
GENERAL FEES Outdoor Li hti Sta rd �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am re�$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transformers u to 10 KVA (� $10
Above 800 Am re �$75 Transiortners over 10 KVA �$20
CIRCUITS / FEEDERS � Transformer / Power Su for Si ns / Outline Li htin �$5
0 to 200 Am re �$5 jtI t ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Ins ection Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri s�$20
Each stem Device or A ratus �$.50 Investi tive Fee
ADDITIONS TO THE GENERAL FEES Reins ' n Fee �$20
MULTIFAMILY DWELLINGS PER UNt TOTAL FEE
3 to 12 Units �$50 Per Unit (minimum total fee is $20)
EaCh Additi0n21 Uflft �$25 FOR INSPECTOR USE ONLY
OTHER ADDITIONAL FEES
Li hU ReVofit �$25 r Fixture
Center Pivot Irri tion Boom ��440
Manufactu�8d Home Park Lots �$25 I hereby certiry that 1 inspected the elect�ical installation described herein on the dates stated:
fiecreational Vehicle Park Sites �$5 "�" �" o��
S arate Bondin I ion �$20 � ��.�-- 3 2 7-G �'.
S'al In 'on �$30 r Hour �"�C"«+ w,�
S ial In ion �$.31 r Mile _ 9 0�
_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED I COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY �- j f��
I I�I{Il IIIII IIIII illll IIIII IIIIIlifll illl� IIf1 I I ��6 �° ��� �
II
� 1 Z 9 7 4 3 8 2�E
Request D te: Rough-in Inspection Required? es ❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call
,,,� 2 �� You must call the inspector when ready! Date Ready:
I certity that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, ar Route No.) City ,. Zip Code
'S%?� � � /1/E ��'�or�e a�S ,3y
Section Township Range Fire No. County
�Na � �—
Occupag�� � �O � �i� /� Pho
✓ ��` � s--rz -- 9ss�
Power Supplier Address
E�ecfica�tr dor,/ �Ompa��me� . �d Contractor License Number Master License Number
�I J « �� , �� aa9ys
Mailing Address ( ontraclor, Company or Owner Perfortning Installation) �
Z�0 6 � �� e ��a �vE . ��� �� //e ii/!✓ �SD �
Authorized Signature (Contrador, pany or Owner Pert I II 'on) p e
.
� �y 6 �� 77�
EB-00001A-13 7/1/2000 D OF ELECTRICT' COPY INSTpUCTIONS ON BACK OF VELLOW COPY