P - 76542REQUEST FOR ELECTRICAL INSPECTION N�
Minnesota Board of Electricit �
1-924-548 � y � :-�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 ���
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us ,�s
Describe -using the back of the white copy if necessary - the w over y this request:
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GENER,4L FEES Outdoor Lightin Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Am�ere l� $25 Sunnlemantal Fra (nl A70
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus a$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS (PER UNITI
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIO
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irriqation Boom (� $4(
Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
Transformer I Power Supply for Sipns I Outline Liphtin $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 Insoection Tri�s an $20
TOTAL FEE n
total fee is $201 �C��
I hereby certify that I inspeded the electrical installation described herein on the dates stated: �
Special Inspection $30 per Hour
Special Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNE�
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19245489
IF NOT COMPLETED WITHIN 12 MONTHS___ �
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Rough-in Inspection Required? ❑Yes No �nspection OtherThan Rough-In: f�Ready Now OWill Call
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You must call the inspector when ready! Date Ready:
I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Street Address ��y
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Name
�����a-�,�yc �
Utilrty Address
lect. Inc. CA 00808
Contractor License Number Master Electrician or Pov�y
l4� 'lmer Lane N. `��'�h �
any or Owner Perfortning Installation) �- �G1
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or Owner P rfo 'ng Installation) Please Provide Two (2) Phone Numbers li
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� P� BOARD OF ELECTRICIN COPV
Technician I