P - 77411REQUEST FOR ELECTRICAL INSPECTION �`�
1-862�884 � �R� �
� Minnesota Board of Electricity a �.
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 <�`
(651) 642-OS00 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
Describe -using the back of the W�1ite copy if necessary - the wcxk covered by this r s—�<L'�4� 1/%�.
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GENERAL FEES Outdoor Lighting Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere @$25 ( Supplemental Fee $20
401 to 800 Am re $50 Transformers u to 10 KVA $10
Above 800 Amoere la� $75 Transformers over 10 KVA (� $ 20
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus $.50
ADDITIONS TO THE GENER4L FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Irrigation Boom @
i Home Park Lots i
Vehicle Park Sites
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiaative Fee
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rotal fee is $20) � +
I hereby cert'rfy that I inspeded the eledrical installation described herein on the dates stated:
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INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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18628842
Date: Rough-in Inspection Required? ❑Yes �o Inspection OtherThan Rough-In: Ready Now ❑Will Call
( �/ '�� You must call the inspector when ready! Date Ready: �� ^�
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I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work aL
Job Site Street Address City
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Township Section Range Fire No. County
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Owner/ pant Name ��� Please Provide Two (2) Phone Numbers Including Area Code
) 57/-g����)316-c�4�3
Electrical Utility Elechical Utility Address
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Contrador / Company Name � + Contrador License Number Master Electrician or Power Limited Technicie
�_ �-•� � �n�� �no`j//Q� LicenseNu �
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Mailing Address (Contractor, Com�pan or Olvner Performing Installation) �`
7� �J�1�'�i%=/�7� T � 1�� N� ��d !/� $����.�02
Authorized Signature (Contractor or Owner rforming Installation) Ple e Provide Two (2) Phone Numbers Including Area Code
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.. CTIONS ON BA . F YELLOW COPV BOARD OF ELECTRICITY COPY EB-00001A-15 8.1. 20