P - 79698` REQUEST FOR ELECTRICAL INSPECTION
�. 2 d 5 0 6 8 �� Minnesota Board of Electricity
�� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-OS00 TTY/MRS 1-800-627-3529
www.electricity.state.mn.us " '
Identify the work covered by this request: ��� ��4��y���
❑NEW ❑REMODEL ❑ADDITION ❑REPAIR
GENERAL FEES Outdoor Li htin Standard @$t
SERVICES / POWER SUPPLIES Traffic Si nai Standard �$5
0 to 400 Am ere �$25 Su lemenial Fee (� $20
401 to 800 Am ere �$50 Transfortners u to 10 KVA �$10
Above 800 Am ere �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li htin (� $5
0 to 200 Am re �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere �$10 Includes the Service andlor Power Suppty up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Tri �$20
Each S stem Device or ratus f� $.50 Investl tive Fee
ADDITIONS TO THE �ENERAL FEES Reins ection Fee (� $20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE sa
3 to 12 Units �$50 Per Unit (minimum total fee is $20)
EaCh Additi0n81 Unit �$25 FOII INSPECTOH USE ONLY
OTHER ADDITIONAL FEES
Li htin Retrofit �$25 r Fixture
Center Pivot Irri ation Boom �$40
Manufactured Home Park Lots �$25 I hereby cerlilly that I inspected Uie elecirical instaNation described herein on the dat�s sfated:
Recreational Vehide Park Sites $5 fl010N" DA7E
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Se rate Bondin Ins ection �$20
S ial In ion �$30 Hour F'""""�`�10N G! °"'�
S ecial Ins ection �$.31 M�e � C����
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPIETED WITHIN 18 MONTNS
POR OfFICE USE ONLY
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Request Date: Rough-in Inspection Required? ❑ Yes No Inspection Other Than Rough-In: Ready Now ❑ Will Cell �.
i'22� Z— You must call the inspector when readyl Date Ready:
I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Address (Street, Box, or Route No.) City Z�p Code
1G -7l���e �� �a�/e
Section Township Range Fire No. County
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OccupaM � � ` � Phone
m r asf4HS � e �763- 79�-- 4�f��-�'
Power Supplier Address
Electrical Contrector / Company Name Contrador License Number Master License Number
/Z�-s ,�r�c� � eA-o �Y�9
Mailing Address (Contractor, Company or Owner Performing fnsTallation)
S7a-o as7� �e�t�,/ 2is�.ti. dJja_.S.S39�`
Authorized Signature (CoMractor, pany or Owner Performing Installation) Phone
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EB-00001A-13 7/1/2000 BOARD OF ELECTHICRV COPY � IN87AUCTON3 ON BACK OF YELLOW COPY