P - 77368REQUEST FOR ELECTRI�L I PE IOJ�L
1�-/ ,� �- 3 4 4 5� Minnesota Board of Electricity ���' ���95 ,* _
1821 University Avenue Suite S-128, Saint Paul, Minnesota �5104
� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy if necessary - the work covered by this request:
EXCE� ENE�GY SAb'�'�;'� St�TiCN
/ICES I POWER SUPPLIES
0 to 400 Ampere (�a $25
iM, COMMUNICATION, REMOTE CONTROL, SIGNALING
UffS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
3 to
Outdoor Lighting Stanc
Traffic Siqnal Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiqative Fee
TOTALFEE �
(minimum total fee is $20) • � b
THIS AREA FOR INSPECTOR USE ONLY
that I inspected the elec�rical installation described herein on [he dates sta�ed:
Center Pivot Irri ation Boom @$40 R0°�"'" o",
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites $5 F��a� ��sPecr�oN on.
Se arate Bondin Ins ection $20 --�� �-^--- �-- t. $
Special Inspection @$30 per Hour exPiaeo aenNOONeo oai
5 cial Inspection $.31 per Mile
THIS 1NSTAL.LATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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17813445
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Rough-in Inspection Required? ❑ Yes }�] No i Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
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:
_ _ _ . —_ _ _ -- _
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iTownship ' Section '��i Range '� Fire No. I County ��
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� Elflctrical Utility � Electrical Utility Address
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CQF�l�'OR�TI�i�i
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License Number
or Power Limited Technician I
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��Mailing Address (Contractor, Company or Owner Performing Installahon)
�'r�0 TERhTTOF:IAL f;OAD, SAIMT F'AUL, �!h! 5�114
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. AuN�orixed Si nature (Contractor or Owner Performing Installation) ��PI ��s Pro i e Twq�( Ph ne Numbers I
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