P - 775201�787-902 4�
Describe -using the back of the white copy
0 to 200 Am ere $5 ��'
Above 200 Ampere @$10
AIAR.M, COMMUNICATION, REMOTE CONTROL,
CIRCLHTS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Li�qhGnq Retrofit @ $.25 per Fixture
!j Cenler Pivoi Irriqation Boom al� $40
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 witi�x�.electricily.state.mn.us
�rp�• Y�f�uPS r• - i T-� r i�
��e �_���._..�,�tl? Tb �i-�V�i�.n:� t �z�7:. .1 .
Outdoor Lightin Standard @ $1
Traffic Signal Standard @ $5
Supplemental Fee Ccil $20
Transformers over 10 KVA $ 20
Transformer I Power Supply for Sipns I Outline Li htin $5
ONE 8 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 Trios (c� $20
TOTAL FEE ;"�s] t
total fee is $201
:�.
:_�
--���t� � -
`"' �l� =
�;,.;
that I inspected the elecirical instailation described herein on the dates stated�,
rate�Bondi Ins tion $20 .,.-� G, - � - (� � 7
S Ci31 InSpOCtion @$30 pe� HOUr E+�aEO aear�ooNEO oATE
S ial Ins ection @$.31 per Mile
�HIS iN�TALl.AT10N MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
� IIII II I� II III II III II III II I�I I) III II II� II �I! I IIII
1787902�y
� � �--' �'- 1 ,� ��� �
�
'j "`"`' i Rou h-in Ins ection Re uired? ❑Yes �
�.� . q� y� 9 P q •�] No I Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
:.s./'i'k:�t7�=� �
T_ You must call the inspector when ready! I Date Ready:
I cettify that I am the �] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
_ T --- _- _ - _. _ _ _ _.-- __
' Job SRe Slreet Address _ I City t'�-� �-� •• 'i � r- v��, c�-:£ r'�
f'� S I h E-" I� il .Z � I._ i._ 1 � i 1 i � �! �.
'. � � {� ! � �., , F r� �-t 1. t. _ ...
����-------------.. -_. _. _----_-.— 9 ___..— �L
I. Township , Section � TRan e � Fire No — I CounN
I
_—_.- ._—..__.
i Ow�erlOccupant Name �-- .. . _ ..- - -.: . . - _ .-�_..
'I -.h:-a i_��_.':;_r• -'{ ri�
:�r.i � �. T ��.�_a�4_�.:Gr�, ;�,�_i � ,�
T.i i ^ikt:
I'i i;l �= i � Y�
Please Provide Two (2) Phone Numbers I
� � � �
i cwu+nz� vwaY � tlectrical Utility Address �-
�'3_i_i_ �_ry!=:^.t �i� — �
j Contractor / Company Name � ; Contractor License Number Master Electrician or Power Limited Techni
'� �'I � � G. . 7 ` .� �, E .' _'E W�!-' ! i � i f ,1 hi � - ' � :- I
i �i`�: -�-'-- �'-- -. _._.. , -�''�: :._.. f„l i1�4�'r-:` '�,LicenseNumber
I , .. ..v.. . ...
, _ ,�..i
`__—._. - __-_ _ ,
' ._-_ . —_ . - — _ __ I
�., Meifinp Address (Contractor, Company or Owner Performin� Installation1 - - � � � � -�-- � ---
,• �' ��5 r A� . .. .a - r-� :
� ..ti `i_t ,t C:.i'��'..t � i.l��. .. ��.. !'�.�i i+.'!!�` a il.:'s... i.i i '�ia i� '`i^� .. t� i��,
�.__ — - . ..- . ___- _ _- — .- ._
— _ _--
� Alt�horised S' nature (Contractor or Owner Performing Installation) Please Provide Two (2) Phone Numbers Including Area Code
I `�o�'r�t 1/ \1
L-i ,1t1 ,p{ \ /
. _
li, �a ; . I � . � i
� —�. _—.— _._ _'_ _— — — . .. �
._— _—. _.'— _— — --'
�-- _—_ __
MISTRUCTIONS QN BACK OF YELLOW COPY BOARD OF ELECTRICITV COPV co nnnn,.. ,� e,