P - 77179REQUEST FOR ELECTRIC L INSPECTION �
1� J� J- 8 31 �, Minnesota Board of Electricity ���IeA �§6 � y��� ���.�'
a � 1821 University Avenue Suite S-128, ain nne t 51 �,
��Q2� (651)642-0800TTY/MRS1-800-627-3529 www.electricity.stafe.mn.us �,��
Describe -using t ack of the white copy if necessary - the work covered by this request:
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✓ICES / PC
0 to 400 Ar
401 to 800
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device orApparatus a$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Traffc Signal Standard
Supplemental Fee @ $
Transformers up to 10 I
Transformers over 10 N
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins tion Trips $20
Investi ative Fee
Reins ion Fee $20
TOTALFEE
(minimum total fee is $20)
THIS AREA FOR INSPECTOR USE ONLY
I herebvi certifvthat t inscected the�eled�al installation described herein orr the dates steted:
�red Home Park Lots $25
nal Vehicle Park Sites $5 Fn+u iNSaecnoN j onTe
Bondin Ins ection $20 �Z` — / ,� �d �
SE1CCfI0f1 $30perHour ExviaEO�aanNnavEO oarE
spection $.31 per Mile
ALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
( IIII II (II I) III I) III II III II III II (II II III
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7,9298314
Date: Rou h-in Ins ection Re uired? ❑Yes o Ins
g p q pection Other Than Rough-In: � Ready Now ill Call
I�/ �� '�� You must call the inspector when ready! Date Ready:
I certify that I am the CENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work ai
Job Site Street Address City I
Co�' -1 S �`�' S+- �iL rid I-e c�
Township Section Range Fire No. County /� �_
.,,�.C.iT�1� c �1.� I c� -e 1�
Electrical Utility Electrical Utility Ad�
Contrador / Comp
13562 CentraF Ave NE
Mailing Address (C ing Installatlon)
763-T57-6202
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IPlease Provide Two (2) Phone Numbers Including Area
�t?(o� S 7 I • �Sri(� )
License Number � Master Electncian or Powertimited 1
�/ � � / License Number
/:
K•�
Please Provide Two (2) Phone Numbers InGuding Area
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