P - 76981REQUEST FOR ELECTRICAL INSPECTION
2 s O 6� e� � 8 �� Minnesota Board of Electricity
,r , 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 copy if necessary - ihe work covered by ihis request:
N10 �-C� -� a tti
GENERAL FEES Outdoor LqhUrq Standard Q! $1
ALARM, COMMUNICATION, REMOTE CONTROL, SIGI
CIRCUITS, CIRCUITS OF LESS THAN 50 YOLTS
i Each S stem Device w Ap aratus $.50
ADDITIONS TO THE GENERAL FEES
Unit
Each Additlaial Unit
Retrofit
:ctiai 330 erHour
x�ion Q $.31 per Mile
1ATION MAY BE ORDERED _
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Transfortners u to 70 KVA $10
Transfortners over 10 KVA (aD $ 20
Transfortner / Power Supply for Signs / Outline L'ghting S5
ONE & iW0 FAMILY DWELLINGS, EACH UNIT
Indudes the Senice andlor Power Suppty up to 500 Amperes, All
Circuits and Two Inspec6on Trips Each DweNing Unit � S80
TOTAL
total fee is ;
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I hereby ceitify that I ir�speded the elechical' d an Ihe da0es st�ed:
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FWOL NSPECTION
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GTEp�IF N9T C9MPL�TED WITHIN 12 MQNTHS ���
RECD JUNT`=°"�-'��`1 �� ��s
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U°�' Rou h-In Ins
5 � O� g pection Required? es ❑ No Inspection Other Than Rough-In: ❑ Ready Now ill Call
You must call the inspec[or when ready! Date Ready:
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I certify that 1 am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspec6on of the electrical wak at
Job Site Sfreet Address
9 - 7�.�h I�� �R��
Township Section Range Fire No. County
Name
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any or c�xmer Nertortnmg In:
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or Owner Performing InstalL•
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ise Number Master ElecUician or
License Number
P�l�/s/e yP�� e� � PRone Number
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