P - 76466REQUEST FOR ELECTRICAL INSPECTION �
1� 7 8 7� 9 O O 8 Minnesota Board of Electricity ��
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �. �:
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.s7ate.mn.us
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SUPPLIES
j Above 200 Ampere (�$10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
to 12 UniLs @ 350 Per Unit
ach Additional Unit @ $25
Fixture
Outdoor Lighting Standard
Traffic Siqnal Standard (�a
� Transformer / Power Supply for Signs / Outline Lighting @$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 Ins�ection Trips C� $20
minimum total fee is
�hat I inspected the electrical installation described herein on ihe da�es stated:
S rate Bondin Inspection $20 L-��- '/-O�
SpBCi21 In5{�eCtion $30 p0f HOU� FxPiaeo; nenNCONEO oarE
Special Ins ction @$.31 per Mile
THt3 INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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I �ale: � ��� Rough-in Inspection Required? ❑ Yes :�] No ��, Inspection Other Than Rough-In: [�Ready Now ❑ Will Call ��i
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, '-' -' I You must call the inspector when ready! �I Date Ready: i
I cerGly fhat I am the f� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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� Job Site Street Address j City t" 1'; � 1.�?._!'. 1 "� i� 't ±{t� �5:r�
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� TpwnshiD .. Section I Range _ Fire No. I Gounty
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rOwnedOccupant Name Please Provide Two (2) Phone Numbers Including Area Code i
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i Electncal Utifity � Electrical Utility Address
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, CDMrac�or ! Company Name I Contractor License Number_ Master Electrician or Power Limited Technician
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'�, MaiWig A.ddress (Coniractor, Company or Owner Performing Installation)
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AuUwri7ad Si nakure (Contractor or Owner Performing Installation) � rplease Provide Two (2) Phone Numbers Including Area Code
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NtlGTR1Y'TlllllC 11N R�(:K AF VFI I f1W (:f]PV Rf1ARf1 (�F FI FrTRI(:ITV CnPV � EB-00001A-15 8.7. 2004