P - 76271• REQI�EST FOR ELECTRICAL INSPECTION
1� 7���� 41 � Minnesota Board of Electricity '�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
' . (651) 64�2-OS00 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
-usiny tha back of the white copy if necessary - the work covered by this request:
� EXCEL EidEFiGY SA��EFi'S S�!IIT�H
GENERAL FEES Outdoor Liuhtinp Standard na. �u1 �
Abova 800 Am re$75 Transformers over 10 KVA @$ 20
CHtCUITS I FEEDERS Transformer / Power Su I for Si ns / Outline Li htin $5
0 to 200 Am re$5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re$10 Includes the Service and/or Power Supply up to 500 Amperes, All
qt.ARb9, COMMUNICATION, REMOTE COMROL, SIGNALWG Circuits and Two Inspection Trips Each Dwelling Un(t @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Addi�onal Insoection Trios (d $20
ADDITIONS TO THE GENERAL FEES Reinspection Fee @$20
FAMILY DNIELLINGS PER UNI TOTAL FEE �eQ �
ro 12 Units @$50 Per Unit (minimum total fee is $20)
Park Lots
I hereby certi(y that I inspeded tha electrical installatlon described herein on the dates sNated: �
� °�
THi$_ INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 72 MONTHS
REC'D .1UN 14 2001
11�111 �I! 1��111 �I II I II � III � III ��I II (H 11111
1'� 9 7 5 4 1 8 0��1�' �'�1���
�� Rough-in Inspection Required7 ❑ Yes -❑ No Inspection Other Than Rough-In: [�,Ready Now OWiII Call
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ei i�, �, /�� Yau must call the inspector when readyl Date Ready:
I c�fify that I am the C�] LI.CENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address City
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area coaa
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Electrical Utility Electripl Utllity Address
�CEL Eh1ERt�Y
Contractar / Company Nama Contractor License Number Master Electrician or P
License Number
I-IU��T ELECTFiI� CQF�F•�RATI.GM C�t Qc]�S�
MaiGng Address (Contractor, Company or Owner Performing Installa6on)
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Authcr�asd 8lgnature (ConVactor or Owner Perfortning Installedon) Please Provide Two (2) Phone Numbers I
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