P - 77170REQUEST FOR ELECTRICAL INSPECTION � �`R"��
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1��� �� 4 9 6� Minnesota Board of Electricity �Q��—�� ��nj � �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 5 144 �
(651) 642-0800 TTY/MRS 1-500-627-3529 www.electricity.state.mn.us ��
Descri using the back f the white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoo Li htin Standard $1
SERVICES I POWER SUPPLIES Traffic Si nal Standard $5 �
0 to 400 Amcere fa� $25 ,. Suoolemental Fee af� $20 i.el T • U
IALARM, COMMUNICATION, REMOTE CANTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Apparatus a(�. $.50
Each Additionai Unfl @ $25
OTHER ADDITI01
Lighting Retrofit @ $25 per Fixture
Center Pivot Ircipation Boom a(� $4C
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 Inspeclion Trips @ $20
Investiqative Fee
total fee is $20) I � � '
I herebv certifv that I insoected the elecVical installation described herein on the dates stated: I
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Special Ins ion $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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182D4966
Date: Rough-in Inspection Required? gYes ❑ No Inspection Other Than Rough-In. �� -�Ready Now ❑ Will Cali
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You must call the inspector when�(eady! Date Ready:
I certify that I am th� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work ai
Job Site Street Address City
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owns��/ Section Range Fire No. Copnty �
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pa N e Please Provide Two (2) Phone Numbers Including Area Code
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Electrical Utility Electncal Utility Address
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s(Contrador, Company or Owner Performing Installatic
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�ctor ucense rvumber nnaster tiectncian or
A � � �! License Number
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9de Two (2) Phone Nu�e�IWing A a Code
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