P - 76570REQUEST FOR ELECTRICAL INSPECTION "i�
�� 7 8 1� g O� 9 Minnesota Board of Electricity ;�.N� `�'
❑ 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104 �
(651) 642-0800 TTY/MRS 1-800-627-3529 �+�n rc. el ectricitt�.stute. mn. us
uescntie -usmg the back ot the whrte copy it necessary - the work covered by tt
Fxr���. �ra��c�• s
GENERALFEES
401 to 800
I
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
� Retroft @ $.25 per Fixture
Pivot Irrigation Boom (�a $4C
equest:
�EF: `S S�IIT��H
Outdoor Lighting Standard
Traffic Siqnal Standard (a� :
Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
Transformer I Power Supply for Signs I Outline Lighting @$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 FEE ��at��
total fee is $20)
that I inspected the electrical instailation described herein on the dates stated:
:� � �- � „�,� C
Special Inspection @$30 per Hour exP�Rec n�,NOON�o oAre �
Special Inspection @ $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
----------------------- ---------------------- ---------------------------- �
IIB II III 11 I� II I� II III II �I II �I II I� (I III I IIII
17819079
� � � c���-. o� ���-� ��.
�a�e. Rough-in Inspection Required? ❑ Yes �] No Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
I, '� !`�' 4! �� _ _ ' You must call the inspector when ready! � Date Ready:
--- -- --
I ce�ity that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
-- -
- -- .. - --
�� Job Site Street Address - � - -� - ���� � -
. .. 'CitY�Fl.i.���� I�i�i
I�cci i`�� �lC..a:��:.�i w7-1Y rlc`y[�•yi"',j{}{�i5
' Township �� � �Section Range , Fire No. . County
I �����
�-- -- -- - -- -- -- - --- -- ---- -- - ---- �� -
'. Owner/Occupant Name , Please Provide Two (2) Phone Numbers Including
szss�ar� i�r�v�D � �I( ) ( )
xcE� F�E�r�t � I,
- --- — _ __ __1_ _- --- _
�Contractor / Company Name ' Contractor License Number Master Electrician or Power Limited Technician
I-I�tC�lT E.C_ECTF;TC C(.lF:�`OF:�1TIUhl (:fi� (7()��._5 LicenseNumber
j- - - __ ._. _- --__.. _ � _._._----. _- __.. _-- ��.
Mailing Address (Contractor, Company or Owner Performing Installation)
' L.��4 TLfiRT?CtIiIAL RC�AU, �H'ThdT F'AI.�L, h1Yi 551Ir�?
_ _ -- --- — - _ - -- - _ ---
� Authorized Si nature (Contractor or Owner Performing Installation) iPlease Provide Two (2) Phone Numbers Including Area Code
�tf�1w CL !(651� b46-��?11 ( �
INSTRUCTIONS ON BACK OF YELLOW COPY BOARD OF ELECTRICITY COPV EB-onon�a-75 x � �nna