P - 76642REQUEST FOR ELECTRICAL INSPECTION � �
2� O 3�� 9 4, 1 � Minnesota Board of Electricity ��
� � �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 ���
(651) 642-0800 TTYIMRS 1-800-627-3529 www.electricity.state.mn.us �gs
Describe -using the back of the wly� copy if necessary - the work covered by this request:
�c'�la�E Jvga �°RntE'L
GENERAL FEES Outdoor Li htin Standard @$i
SERVICES I POWER SUPPLIES Tra�c Siqnal Standard an $5
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or A paratus @$.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Each Additional Unfl @ $25
OTHER ADDITIO
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irriaation Boom (a? $4(
Transformers over 10 KVA $ 20
Transformer / Power Supply for Signs I Outline Lightinq $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiqative Fee
TOTALFEE
total fee is $20) q�� 6 v
I inspected the electrical installation desaibed herein on the dates stated: �
Special Inspection $30 pC� HOUf E%PIREDIAfl4N00NE0
S cial Ins ection $.31 per Mile
�THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NO'
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dPLETED WITHIN 12 MONTHS
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g spection Required? ❑Yes �No Inspection Other Than Rough-In: ❑ Ready Now �Will Call
!o2'5-06
You must call the inspector when ready! Date Ready:
I certify that I a ,� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site SV Address ��Y
S a(� TN 5 T P�1 t F'�.� �p \ E�
T nship Section Range Fire No. County
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Owner/Occupant Name 1 Please Provide Two (2) Phone Numbers Inciuding Area Code
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Gonhactor / Company Name Contrador License Nqumbe Master Elechician or Power Limited Technician
�O�J3 � A3 S O(i`� �Z tC.�i�"� 1 L CO : e, /t C� ���i 1 License Number
Mailing Address (Conhador, Company or Owner Perfortning Installatian)
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Au ' ed Sign re(Contractor or Owner Perfortning Installation) Please Provide Two (2) Phone Numbers Including Area Code
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INSTRUCTIONS O CK OF YELLOW COPY BOARD OF ELECTRICIN COPY FRlIl1M1A_15 n�>me