P - 77715� REQUEST FOR ELECTRICf�L INSPECTION �
� ��8 � � � � 4, � ,��� Minnesota Board of Electricity .��;�� +d��� �. � � :
I ,; ' 1821 University Avenue Suite S-128, Saint Paul, Minneso �`
�Tm i5 �45 LQ� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
escribe -using the back of the white copy if nq� ssary - the work covered by this request:
iUY 1/,P�l � l� ,�YY�'1
GENERAL FEES Outdoor Lighting Standard $1
SERVICES I POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Amcere (� $25 Su lemental Fee $20
ALARM, COMMUNICATION, REMOTE CANTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus a$.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units (a� S50 Per Unit
� Retrofit @ $.25 per Fi�Aure
Pivot Irrigation Boom @ $4L
ictured Home Park Lots @ $
tional Vehide Park Sites an
ecial Inspection @ $.31 per Mile
INSTALLATION MAY BE
�I�� ����il �I ��i �� I�� �� �I� �� �I� �� ��� �� ��� N�I ��
18592423
Transformers u to 10 KVA a$10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns I Outline Li htin $5
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 ection Tri s $20
Investi ative Fee
Reins ection Fee $20
TOTALFEE
(minimum total fee is $20) , —
I hereby certity that I inspeded the electrical installation described herein on the dates slated: I
IF NOT COMPLETED
��:__ c ,�.__
� -�I-oS` I
"`d' � Rough-in Inspection Required? ❑ Yes �lo Inspection Other Than Rough-In: ❑ Ready Now ill Call
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 ite S Address �y
J �� ' � �cll�
To ship Section Range Fire No. County _
S Gt..
ailin Address Contractor, Compan�
J
o' ign re(ConVactor or Owi
� �y�—,a-�,.�
INSTRUCTIONS ON BACK OF YELLOW COPY
uniay
1
)7�1 k�1"l9 ( )
`- -.� /.,.=�I ZY�� !/
BOARD OF ELECTRICITV COPY
Master ElecUician or Power LimRed Technician
License Number
'� /
Two (2) Phone umbe ncluding Area Code
D�� i )
c rnnn�e�< e. om.