P - 76595Q REQUEST FOR ELECTRICAL INSPECTION ��
( �� Q� e.�e �� 3 3� Minnesota Board of Electricity �-- �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �,.
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us �;;�s�
Describe -us' the back of the wp'� copy if necessary - the work covered by this request:
l' C�.-� 5 �•�1 l' -1- y7 ��S-
GENERAL FEES Outdoor Lig ting Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere $25 Supplemental Fee $20
401 to 800 Am ere $50 — Transformers u to 10 KVA $10
Above 800 Am ere $75 Transformers over 10 KVA $ 20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns I Outline Li htin $5
0 to 200 Am re $5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes the Service and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A paratus $.50
ADDITIONS TO THE GENERAL I
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Liphtinq Retrofit (�D $.25 oer Fi�Rure
Fee @ $20
TOTAI
iimum total fee is
I hereby certify that I inspected the electrical installation desaibed herein on the dates stated:
lome Park Lots $25
!hlde PBfk SiIPS $5 F rvsaECnorv oare
Ins tion $20 � ��� 3 —p �C"
IO� $30perHour EXPIREDIABANOONED pq�
ion $.31 per Mile
ATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
��I� �� ��� �� (�� �� (�� �� ��� �� ��) �� ��� �� ��� �� �� � - 3
18421339 C��D� DQ��
Date:
�� Rough-in Inspection Required? ❑ Yes o Inspection Other Than Rough-In: � Ready Now ill Call
��� 9— O� You must call the inspector when ready! Date Ready:
I certify that I am the �ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site SVeet Address ��y
� �d e�, � t� � �-� � (
Township Section Rang Fire No. County
Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
. � �C.mU�'1 l.� (�� _��7 �-J�'�' )
Anbka, MN
Mailing Address (Contrac o m a r(
Authorae�f3' naWre onU "ror
r, �
INSTRUCTIONS ON BACK OF YELLOW � PY
License Number Master ElecVician or Power
O I��� License Number
Please Provide Two (2) Phone Numbers InGuding Area Code
�4� 7S�-�an% )
OF ELECTRICIN COPY FR110M1A_15 n� om..