P - 75634REQUEST FOR ELECTRICAL INSPECTION ' �-
1��� Q� 2� 6 � Minnesota Boar�-of �le�ricity ,
1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104
, . • (651) 64F-0800 TTY/MRS 1-8Q0-627-3529 www.electricity.state.mn.us
Describe -usirig tl�& back of the white copy'rf necessary - the work covered by this request: /'A)% J A���yJt—J j/
VICES / POWER SUPPLIES
0 to 400 Ampere a$25
401 to 800 Ampere Q$50
Above 800 Am�re Q $75
;UITS / FEEDERS
0 to 2� Am�re @ $5
Above 200 Am�re @$10
2M, COMMUNICATION, REMOTE CONTROL, SIGNALIP
:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDRIONSTO THE GENERAL FEES
TIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Addfional Unft @ $25
OTHER ADDITIONAL FEES
Lighang Retrofit $25 per Falure
CeMer Pivot Irti atlon Boom $40
Manufactured Home Pazk Lots $25
Recreational Vehicle Park Sites $5
Se te Bor�din Ins���don (�a, $20
S Ir�s ecGon Q$30 per Hour
S Ins on $.37 r M�e
S INSTALLATION MAY BE ORDERED I
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18202564
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ONE & 1W0 FAMILY DWELLINGS, EACH UNIT
Includas the Service and/or Power Supply up W 500 Amperes, All
C'ircuiGs and Two Inspecdon Trips Each Dwening Unit @$80
AddiHonal InspecUon Tdps @ $20 � _
Imestlaative Fee _ _ �i
TOTAL FEE I � v— v•
(minimum total fee is $20) � , d�j
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I herebY cerdfY that I inspected the eledricel Instellatlon desalbel�ti�hra�r�'
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VNECT D-IF NOT COMPLETED WITHIN 12 MONTHS
�OR OfF CE U$E O�rLr ar'`
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Rough-in Inspecdon Requtred? ❑ Yea ❑ No I�p�tlon Other Than Rough-In: � Ready Now � Witl Cali
��� C� �[ °�'% 1 You must call the inspador when readyi Date Ready.
I certify that I am the ❑ LICFJVSED CONTRACTOR CO ANY ❑ OWNER and hereby request inspection of the elech ical work at
Job S Street Addr�s a ut, ""�„ � �ryy
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/ Company Name
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i Signature (CoMrador or Owner I
G�dIS7�YV�9 ��✓ki
)NS ON BACK OF YELLOW COPY
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Contrador Ucense Number Master Eledridan or Power Limited T
Licer� Number
Install�a,f�i n)
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talletion) Please Provide Two (2) Phone Numbe�s Induding Area
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