P - 77045REQUEST FOR ELECTRICAL INSPECTION
� Minnesota Board of Electricity p��S��� �.
,,, �' 8 8�� 8 g 8 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:
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GENERAL F Outdoor Lightin Standard $t
SERVICES / POWER SUPPLIES Traffic Siqnal Standard na, $5
Above 800 Am ere a$75
CIRCUITS I FEEDERS
0 to 200 Am re $5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Au�aratus C�D $.50
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIO
Liphtinq Retrofit (iil $.25 per Fixture
Fee $
up to 10
over 10 f
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 Inspedion Tri s $20
Investigative Fee
Reins ection Fee $20
TOTALFEE _
(minimum total fee is $20) �'� •
THIS AREA FOR MSPECTOR USE ONLY
I hereby certiy that I inspected fhe electrical installation described herein on the dates stated:
%.
Special Ins ion $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
_ ._,
I II�I illl� ��I�I II I�� �IIII II I�I II III IIIII ��I I�
18858985
Date: Rou h-in Ins ction R uired?
g pe eq ❑ Yes No Inspection O[her Than Rough-In: ❑ Ready Now Will Call
�� I(��.v 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:
Job Site Street Address � Ci,� �
. . — -� , r�, � , 'i1 �-_._ : � . ` � f _
Utility
I Contractor
\ / \ /
Electrical UGlity Address
. ,� ��C 1 � V ervece Contractor License Number Master Electrician or Power Limited Technician
,� . License Number
o y r P i I�tion)
. . � . ■ ■ � � � r i A A � . . .
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