P - 77576REQUEST FOR ELECTRICAL INSPECTION
I 1� 8� 7`�, 0 2 2 Minnesota Board of Electricity �-
1821 University Aven e Suite S-128, Saint Paul, Minnesota 55104
< (651) 642-0800 S 1-800-627-3529 www.electricity.state.mn.us
Desaibe -using the back of the whita copy if ssary - the work cov uest: �OO �. �l� �
GJ��e � ,�- G i`
GENERAL FEES Outdoor Li hting Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere $25 Supplemental Fee $20
401 to 800 Am re $50 Transformers u to 10 KVA $10
Above 800 Am re $75 Transformers over 10 KVA $ 20
CIRCUITS / FEEDERS Transformer I Power Su I for Si ns I Outline Li htin $5
0 to 200 Am ere $5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere $10 Includes the Senice andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CANTROL, SIGNALING Circuits and Two Inspection Trips Each Dweiling Unit @$80
UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
fIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional UnR (� S25
i Home Park Lots i
Vehicle Park Sites
�spection @ $.31 per Mile
'ALLATtON MAY BE ORDERED
II�IIIIIIIIIiiiIIlilllillllllllilllllN��l�
18570226
TOTALFEE
total fee is $20) ZD �-
that I inspeded the electrical installation desaibed herein on the dates stated:
DATE
:�'�------�� -�°" � L.
aeo on�
NOT COMPLETED WITHIN 12 MONTHS
,.,L � � :,t..:=
Date: Raugh-in I�spection Required? ❑Yes �o Inspection Other Than Ro h-In: eady Now OWill Call
6�/�`bj You must call the inspec[or when ready! Date Ready: 6�����l+
�,
I certify that I am the�10ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspec6on of the eledrical work at
Job S8e Street Address C�
� �"`' � /�C E �d
Township Sedion Range Fire No. Countv
Name
Mailing Ad�rtss (Contractor, Company or
1
Authorized Signature (Con actor or O
INSTRUCTIONS ON BACK OF YELLOW COPY
�-7339 ( )
I Contractor License Number I Master Electrician or
� �/ � License Number
�
/
BOARD OF ELECTRICITY COPY
�E
Please Pro�Two
It�� �Q
\ / I
FR11(IM11C.15 R � �Mld