P - 77564REQUEST FOR ELECTRI AL I SPECTION `'���
1-842-1�6 ��' Y �` �r�
� Minnesota Board of Electricit ���� � � �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 5104
�1 � r �1Q�� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricily.state.mn.us �;�yi�
�Y V
Describ the back of th ite copy if necessary - the work covered by this request:
C�-v.�.�0 (05 t -�1�"l • -1$� S
GENERAL FEES Outdoor Li htin Standard $i
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere Ca) $25 Supplemental Fee @$20
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Ap aratus �$.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIO
LiqMinq Retrofit an. $.25 per Fixture
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 Ins ion Tri s $20
Investi ative Fee
Reins ion Fee $20
TOTAL FEE `�
(minimum total fee is $20)
THIS AREA FOft INSPECTOR USE ONLY
I hereby certHV that I inspeded the electrical installation described herein on the dates stated:
- Qr i
5 ecial Inspection
THIS INSTALLA
Hour ����n��,,,�,n�„�.��
Mile
4Y BE ORDERED DISCONNECTED IF NOT COMPLETED WITh
IIIII �IIII IIII) IIIII IIIII IIII) II�II IIIII �� I�
18421867
Date: Rough-in Inspection Required? ❑Yes �No Inspedion Other Than Rough-In: ❑Ready Now �Will Call
lss' ��'�� You must call the inspector when ready! Date Ready:
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site SVeet Address � C�Y �r `��
] l l � 3Y�' (�.�
Township c[ion Range Fire No. Counry
����
Owner/ ccupant Name Please Provide Two (2) Phone Numbers Including Area Code
i i.t'� C-� l�'E- � 5 Y? +'1 — ,� �
Electn Utility Electrical U6IityAddress
�v� � ConVador License Number Master Electrician or Power Limited Technician
� j � � License Number
r
g Installation)
_, < <
Please Provide Two (2) Phone Numbers I
� / \ �