P - 78089REQUEST FOR ELECTRICAL INSPECTION
1�� O 1- 9 4 7 8� gfp� Unrversity Avenue 8u'��te S- 28, SaiM Paul, Minnesota 55104
(651)642-0BOOTTY/MRS1-800�27-3529 www.electriciry.state.mn.us
❑ NEW REMOD ❑ ADDITION 0 REP scribe -using the back of the white copy if necessary - the work covered by this request:
��
GENERAL FEES Outdoor Li h6n Standard $1
SERVICES / POWER SUPPLIES Traific Sianal Standard O SS
0 to 400 Am ere E25
401 to 800 Ampere @ $50
Above 800 Am ere $75
CIRCUITS / FEEDERS
to 200 Am re y5
Above 200 Am re E10
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
2 UniGs @ a50 Per Unit
Additional Unit �1325
OTHER ADDITIO
ng Retrofit � $.25 per Fixture
:r Pivot Imga6on Boom � $4(
faclured Home Park Lots � 9
:a6onal Vehicle Park Sites �
Transfortners u to 10 KVA y10
Transformers over 10 KVA �$ 20
Transfortner I Power Supply for Signs I Outline Liqhting (� $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
Addi6onal Inspection Trips @ $20
Inves6aative Fee
(minimum total fee is $20) � � 0, 3 CC�
iH15 AREA FOR INSPECTpi USE p1V
I hereby ceAify that I inspected the electrical inst�la6on described herein on the dates stated:
<� � �3-zv�<
MTE
�—_ __ Z� � �-- C
�STALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS �_
I ' �� l��fi�
I�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII��I� ����
15079478 � �
I 6ertify�at I am the
Job Sile Address (Stre
ra•._h�
� -S
Rough�n Inspection Required? es ❑ No Inspecfion Other Than Rough-In: ❑Ready Nav II Call
� You must call the inspecta when ready! Date Ready:
�ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and he2by request inspection of the etectrical work at::
a Route No ) � City Zip Code
'�r/U,E"-�r !�b � sy Ss`y.� /
..... , „o.., ..o,,,�
O L �,�,l� /�TJ
Power Supplier
Con / Company Neme
��r ��c�
�I_ g�� �tractar� Company or Owner
Authorized SignaWr� nt O
INE7RUC710N8 K OF YE COPY
���' L/2 -- ��-�
v���l:�
Contractor License Number Mast� Electrician or Power Limded Technician
C %Q A ,�D��� License Number
L (�/�1
rming Installation)
- �r �ilv�. �i� ,S S'/o /
BOARD OF ELECTRICITY CAPY
yy yL�
EB-00001A-14 8.1.2002