P - 76464REQUEST FOR ELECTRICAL INSPECTION �
1-787-924 8 y ����
❑ Minnesota Board of Electricit �r-
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 x�x�w.electricity.state.mn.us
Describe -using the back of the white copy if n_ the �I��Cqv�yby,�,is. rac�est: �. ,:�• �,- -,�
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FEES
0 to 400
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CiRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
�ach Sysfom Device or Apparatus @ $.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @ 550 Pe
Each Additional Unit @
25 per Fixture
n Boom (�a $4[
Outdoor Lighting Stand
Traffic Signal Standard
Su�olemental Fee (� $
� Transformer I Power Supply for Signs I Outline Lighting @$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
Additional Inspection Trips @ $20
Investioative Fee
TOTAL FEE s:!!.
mum total fee is $201
I inspected the eledrical installation descnbed herein on the dates slated:
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S cial Inspection �d $30 per Hour `^"'"`� "'"'"°„"`� '� """ I
�pecial Inspection @ $.31 per Mile
TMI,S l{$STALLATIbN MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS __�
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-�. ���� '��. Rou h-in Ins ection Re uired? ❑ Yes
. g p q i[] No �, lnspection Other Than Rough-In: 'Ready Now Will Call
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'. You must call �he inspector when ready! . Date Ready:
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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-� Owner/Occupant Name � Please Provide Two (2) Phone Numbers Including Area Code
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��. E�eafrical UtiAty � Electrical Utility Address
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�� Contractor / Company Name I � Contractor License Number '� Master Electrician or Power Limited Technic
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� Mailwig Address (Contractor, Company or Owner Performing Installation) � �
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I Autltorizad S' nature (Contractor or Owner Performing Installation)� � Please Provide Two (2) Phone Numbers Including Area Code
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