P - 77138� REQUEST FOR ELECTRICAL INSPECTION ����
1��! ��+.0 - 4 9 0� Minnesota Board of Electricity �- .�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 :�'
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using �he back of the white copy'rf necessary - the work cover� by this request:
: i i . w �
SUPPLIES
401 to 800 Am ere $50 -
Above 800 Am ere $75
CIRCUITS I FEEDERS
0 to 200 Am re $5
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CANTROL, SIGNAIING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
MULTIFAMILY DWELLINGS PER UNf
3 to 12 Unfls @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIO
Liahtina Retrofit (�a $.25 per Fixlure
Standard
Transformers u to 10 KVA $10 S aT� "
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ction Tri s $20
Investlgative Fee
Reins ection Fee $20
TOTALPEE S
(minimum totai fee is $20) ?j I �
THIS AREN FOft INSPECiOR USE ONLY
I herebvi certifv that I inspeded the electncal installation desaibed herein on the dates stated:
���
Mile
ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12
��i� �� ��� (� �_� �I III �� �� �� ��� �� ��� �� N) �� ��
18204909
Date: Rough-in Inspection Required? ❑ Yes �No Inspection Other Than Rough-In: ❑ Ready Now 1p(ill Call
� 1 a 3 ag- You must call the inspector when ready! Date Ready:
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY l�( OWNER and hereby request inspection of the electrical work at:
Job Site Street Address City �, �
1 ( C� 3 `�� ,� !� � �r�
Township 'on Range Fire No. County
� ay �k�
Owner/Occupa ame j �� Please Provide Two (2) Phone Numbers Includim� Area Code
vi� � r /L s-�� (� 77s-9o9s(bs7) -6� 3q) Z
Eledrical Utility Electrical Utility Address
XC2 ` - � ° b � a£f— �/�/� �S �+'� �`� 5!0�
Contrador / Company me ConVactor License Number Master ElecUician or Power Limited Technician
� N � License Number
Mailing Address (Conhaclor, Company or Owner Performing InsJ�lla6on)
Authorized Signsture (Contr tor or wner Pe rtni '� Please Provide Two (2) Phone Numbers InGuding Area Code
d�1) -� �s-�a�r (� ) b� � -3�)Z
����A� �nt��ue iu� e�nv �e v�� � n�u nnnv onnon nc ci ��roi��rv rllov FLLl1l1M1 A_1S R 1