P - 76512REQUEST FOR ELECTRICAL INSPECTION �
1�.7 C� �� 5 4�� Minnesota Board of Electricity �-, ,:�
1821 University Avenue Suite 5-128, 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 cop f necessary the work covered by this request:
/�`v,�n�A� ,�,� /�'�EL ' �' 3 Ci2cv� �s f.,✓ �sEin�y"
GEN L FEES tdoor L' htin Standard @$1
SERVICES / POWER SUPPIIES Traffic Si nal Standard $5
0 to 400 Amoere an $25 . d. s��n�iPmanrai FPP n a�n
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGi
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus $.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighting Retrofit @ $25 per Fixture
Center Pivot Irripation Boom an $40
Special Inspection @ $30 per Hour
S cial Inspection $.31 r Mile
THIS INSTALLATION MAY BE ORDERED
i�ll II III ll ili II I I I I I III I I III II I I I I I III �� I�I
19625482
Transformers over 10 KVA $ 20
Transformer / Power Supply for Signs / Outline Liqhtin $5
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 Insoection Trios Ca� $20
TOTAL FEE �
total fee is $20) ip0. -
I hereby cedify that I inspected the electripl installaGon desaibed herein on ihe dates stated: �
IF NOT COMPLETED
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� uate: Rough-in Inspection Required? ❑ Yes �No Inspection Other Than Rough-In� Ready Now ❑ Will Call
��/ /� `° You must call the ins ector when read !
p y Date Ready:
I certiiy that I am the,.� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Street Address City
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Township Section Range Fire No. County . �
=r/OCCUpant Name Please Provicle Two (2) Phone Numbers Including Area C
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rical Utility Electncal UtilityAddress
�actor / Company Name Contrador License Number Master Eledrician or Power LimRed Te
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�1g Address (Contractor, Cp mpany or Owner Performing Installation)
/ q�� �►•dOv�e .�v� N �' �
orized Signature (Contractor or Owner Performing Installation) Please Provide Two (2) Phone Numbers InGuding Area C
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;UCTIO S ON BACK OF YELLOW COPY BOARD OF ELECTRICITV CnPV vo I,..�.�,,.. ,�