P - 78719REQUEST FOR ELECTRICAL INSPECTION
1 3 4 7 3 0 6 eg Minnesota Board of Electricity
� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529
' www.electricity.state.mn.us
Identity the work covered by this request: ` A y� � d o
/' � t /Uii
❑ NEW REMODEL ❑ ADDITION ❑ REPAIR L� w"�^, ��° t •� v
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Tratfic Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transfortners u to 10 KVA �$10
Above 800 Am e�$75 Transfortners over 10 KVA �$20
CIRCUITS / FEEDERS Transfortner / Power Su for Si ns I Outline Li Min �$5
0 to 200 Am re �$5 ID ONE � TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re�$10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two In 'on Tri Each Dwelli Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins bn Tri s�$20
Each S stem Device or ratus �$.50 Investi ative Fee
AoDITIONS TO THE GENERAL FEES Reins ection Fee �$20 ____ '��
Units � $50 Per Unit
dditional Unit � $25
OTHER ADDITIOP
� Retrofit � $25 per Fixture
Pivot Irtiaation Boom � $4(
Park Lots �
Park Sites �
soectian � $�
t IrerebY cerMy that I
total fee is
installation described herein on the tleoe
� - c,�'s
--�
�:.� g :T = �
�� ^ FOR OFFICE USE ONLY
fl�Ill��IIIIiIIlII111�II�IIIIIIINilllllllllllilll � /�,�6�
�E 1 3 4 7 3 O 6 1 3E '" '��'s�
Request Date: Rough-in Inspection Required? Yes ❑ No Inspection O[her Than Rougfrin: ❑ Ready Now �� Cal�
—�� �/ You musi call the inspector when ready! Date Ready: �
I cerMy that i am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elecUical work at:
.bb Address (Street, Box, or Route No.) r CdY�j�/ Zi�� �
� Z �
Section Township Range Flre N� Counry �
�O �
P� /1 '/ Phone
OCCU/ !-r JM IW / l..i� � / /N/! � � `� . �/ �
i P�a�
rector / Compj ny Name �� Contractor License
-s Cl�cf �% 4 ��t�fi�� 1.�- �33d.
�s (Conhactor, Company or Owner Perfortm IlatQn)
� �Z 3 rQ�-c. ��s�t/n�x� r
�nature (Contractor, Com y o Owner PeAorming Installation)
�� ����
����Zppp BOARD OF ELECTRICRY COPY
vr�l� �
Master License Number
55 ���� I
INSTAUCTIONS ON BACK OF YELLOW COPY