P - 77053REQUEST FOR ELECTRIC L INSPECTION �
1 � ('�� �� � � � � Minnesota Board of Electricity � -���p �� � :�
1821 University Avenue Suite S-128, amt Paul, innesoTa 55104 �
(651)642-0800TTY/MRS 1-800-627-3529 www.electricity.state.mn.us �;�t�
Describe -using the back of the white copy'rf necessary - the work covered by this request:
/ POWER SUPPLIES
0 to 200 Am ere a$5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Ap aratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Li htin Retrofit $25 per Fi�Rure
Center Pivot IrriaaSon Boom Ca1$40
pection @ $.31 per Mile �
�LLATION MAY BE ORDERED DN
IIII II III II III II II) II III II III II III II III �� I��
1,9269331
Tra�c Signal 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
ivir��r�� �^�
total fee is $20) � - J �!
I hereby certiry that I inspected Ne elecfrical installation described herein on the dates staled: �
� �� � i i — i
E%PIPEDIABANOONEO DA1
:CTED IF NOT COMPLETED WITHIN 12 MONTHS
Date: Rou h-in Ins ctibn Re uired? ❑ Yes o Ins
g pe q � 1 pection Other Than Rough-In: ❑ Ready Now II Call
�Q' a� 1� You must call the inspector when ready! Date Ready:
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at•
Job Site Street Address Ci[y
I( na('`-i 1... Q�r'� � I'C? . �A i C�. Q G,l�l
� Mailing Address
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.IYI. Electric Services I n��orLicenseNumber IMasterElectridanor
��,�, � n � LicenseNumber
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763) 783-7080 �
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