P - 77049REQUEST FOR ELECTRIC L INS ECTION /� �
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1= 9 2 6� J��� Minnesota Board of Electricity �o�� Q��j3(O k� �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �. '
(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 lhis request:
GENE E Outdoor Lighting Standard @$1
SERVICES / POWER SUPPLIES Traffic Siqnal Standard na $5
Above 200 Ampere � $10
ALARM, COMMUNtCATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
Each Additional Unit @ $25
OTHER ADDITIO
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irrigation Boom na $4(
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 Ins ection Tri s a$20
Investigative Fee
Reinscection Fee Cd $20
total fee is $20) � p�j =
I hereby certify that I inspected the electrical installation described herein on the dates stated:
flWGHIN DATE
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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1�9269273
uate: Rough-in Inspection Required? ❑ Yes �tJo Inspection Other Than Rough-In: ❑ Ready Now$9�ill Call
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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 A � Cit� � q^
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Please Provide Two (2 Phone umbers Including Area Code
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al Utildy Address
CA� Contractor License Number Master Electrician or Power Limited Techni�
C � License Number
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� I on � Ple rovide Two (2) Phone �mbers Including rea Code
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