P - 78421REQUEST FOR ELECTRICAL INSPECTION
°� Minnesota Board of Electricity `��
1� J 4 7� 3 2 9 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
f, (651) 642-0800 TTY/MRS 1- 00-627-3529
www.electricity.state.m .us
Identify the work covered by this request: � /
f
❑ NEW ❑ REMODEL ❑ ADDITION gF1EPAIR � S�
401 to 800 Ampere � $50 `
Above 800 Ampere � $75
�UITS / FEEDERS
0 to 200 Ampere � $5
Above 200 Ampere � $10
RM, COMMUNICATION, REMOTE CONTROL,
�UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus �$.50
ADDITIONS TO THE GENERAL F
OTHER ADDITIONAL
ReVofit � $25 per Focture
'ivot Irrigation Boom � $40
tured Home Park Lots � $25
�nal Vehicle Park Sites � $5
� Bondina Insoection � S20
Outdoor Li htin Standard � $1
Traffic Si nal Standard � $5
Su �lemental Fee f� $20
Transfortners u to 10 KVA �$10 ��—
Transformers over 10 KVA � $20
Transformer / Power Su for Si ns / Outline Li htin �$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Indudes the Service andlor Power Suppty up to 5W Amperes, All
Circuits and Two Inspection Trips Each Dwellin Un� �$8f
Additional Ins ection Tri s�$20
Investi ative Fee
Reinsoection Fee � $20
(minimum total fee is $20) �/.
us�cro{R usE an�r s-� �`
�, /L�Y�` �a /�LG L /
herein on the dates steDed:
� iai m ion �e �:w er nour --'---'—' /2 �,,
S ial In ion �$.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MON'
FOR OFFICE U8E ONLY �
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�u/i �!y � I You must call the inspector when readyl I Date Ready: I
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY �WNER and hereby request inspection of the electrical work ak
Job Address (Street, Box, or Route No.) Ciry Zip Code
lY8�1' G�{�' �4UE r S-S�/ 32
Section Township � Ran� Fire No. County
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OccupaM Phone
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Power Supplier ress ' /�
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Electrical Contrector / Name �s �±� y Contractor License Number Master License Number
Mailing Address (Contrador, Compeny or Owner Performing Installation)
lY ; G y�''" Au`� /7✓t/ �`S�r � Z
Aut orized Signature r, Company or Owner Perfo ing Installatlai) Phone
?63 -SSG ' 8'72 '7
. EB-00001A•13 7/1/2 BOAHD OF ELEC7AICRY COPY INSTqUCT10N3 ON BACK OF YELLOW COPY