P - 80035' REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
1-396-120 � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529
www. electricity. sta te, mn. us
Identity the work covered by this request:
d'NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR
to
Above 200 Ampere � $10 �
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus �$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY OWELLINGS (PER UNI� .
3 to 12 Units �$50 Per Unit
OTHER ADDITI(
Lighting Retrofit � $25 per Fixtur�
Cerrter Pivot Irrigation Boom � $4
Manufactured Home Park Lots �
Recreational Vehicle Park Sites �
XCEL ENERQY SAVER'S SWITCH
Transformers over 10 KVA � $20
Transfortners / Power Supply for Signs / OuHine Lighting �
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unft �$f
Additlonal Inspection Trips � $20
FOR INSPECTOfl USE ONLY
I hereby certity ihat 1 inspecletl Ma
ROUGH IN
FiNAIINSPECTION /^ .
TOTAL FEE
total fee is $20)
describetl herein on the tletes steted:
DATE
' �O—�
FOR OFFICE USE �ILY
I I IIIII I�il I{NI III� Nill IIIN IINI �� I�
* 1 3961 206* ���� �b�0
Reque���j/Q'� Rough-in Inspection Required? ❑ Yes IRNO Inspection Other Than Rough-in: � Ready Now ❑ Will Call
You must call the inspector when readyl Date Ready:
l certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address�, so���r�E c��y F�� z�p coaa ��
M�'
Section Township Range Fire No. County /��(/�
Occup�qi, ,�,1� � M Phone
YYCaIG
Power Su li r E��� Address
E�eCtric�./ j�ALWP[11LLJ���T�� Contractar Lic�p,Se y�y(�q@� Master License� Number
�t�. i rti�r �.r� ��t�txs
Mailin9 L:JW 1 tlihil i G]KIAL�FiUAU � P�iAl1V 1"F'%51U��NIN �.Si i r{
Authoriz ' nature (C�ptractol mpan or Owner Perfortning Instellatlon) Phone �1 ���11
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EB-00001A-13 711/2000 BOARD OF ELECTRICITY COPY INSTRUCTIONS ON BACK OF YELLOW COPY