P - 78155REQUEST FOR ELECTRICAL INSPECTION
,�� `5 7 6-18 4❑4 Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
651 642-0800 TfY/MRS 1-800-627-3529 www.electrecity.state.mn.us
❑ NEW ❑ REMODEL ❑ ADDITION REPAIR Describe -using the back of the white ecessary - Ne xrork covered by this request:
H �c..0 . "� � I r95J � 11en. ����ndM = �'�
SERVICES /
iM, COMMUNICATION, REMOTE CONTROL, SIGN�
:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus 5.50
ADDITIONS TO THE GENERAL FEES
iIFAMILY DWELLINGS (PER UNin
3 to 12 Units @$50 Per Unit
Each Addi6onal Unit @ $25 � �
OTHER
Ligh6ng Rehofit @ $.25 G
Center Pivot Irriaation Bo
Su lemental Fee $20
Transformers u to 10 KVA $10
Transfortners over 10 KVA $ 20
Transformer / Power Su for Si ns I Outline Li htin $5
ONE & 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
Fee
( TOTAL FE j I �O �
minimum total fee is $20
THI$ AREA FOR MSPECTpi USE ONLY
I hereby cer6y that I inspected the electrical insfall�on described herein on the dates stated:
♦ci�n.ic r Gin JIIGJ iJ . _ ._ __.._.. , � ,•••��
arate Bondin Ins tion $20
S ial Ins 'on $30 r Hour E%PIREDiAdVOplE�
S ial Ins 'on $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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15761844
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Request Dffie: Rough-in Inspedion Required? ❑ Yes Inspedion Other Than Raugh-In: Ready Now ❑ Will Call
—� �Q You must call the inspedor when ready! Dale Ready:
I certify that I am tlie• f�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at::