P - 77562REQUEST FOR ELECTRICAL I SP�j T N �•"'�'�
1�(�'J �� �-12 6�k °; Minnesota Board of Electricity ��Q� Ol��
1821 University Avenue Suite S-128, aint Paul, Minnesota 55104 >�
• (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy if necessary - the work covered by this request:
IGr�A.H° �eP.v� / - .'�� - !3l�rr �'o. /'- �tr..,r�.,✓'� sw t �lv�
GENERAL FEES Outdoor Lightin Standard $1
SERVICES I POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere $25 fj 6 � Sup lemental Fee $20
401 to 800 Am re $50 Transformers u to 10 KVA $10
Above 800 Am ere $75 Transformers over 10 KVA $ 20
CIRCUITS I FEEDERS Transformer I Power Su I tor Si ns I Outline Li hti $5
0 to 200 Am ere $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes the Service andlor Power Suppiy up to 500 Amperes, Ail
ALARM. COMMUNICATION. REMOTE CONTROL. SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
fIFAMILY DWELLINGS (PER UNIT)
3 ta 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irtiqation Boom na $40
io�urtt �/ �
total fee is $20) 7� �
I hereby certify that I inspected the elecVical installation described herein on the dates stated:
RWGHIN DRTE
FINl�IIN$PECTION ' OAiE
� - —�- � �
on @$.31 per Mile I I
ATION MAY BE ORDERED DISCONNECTED IF NOT
Ilii II III II III II III II III II III II III II III �� I��
18271262
Date: Rough-in Inspection Required? ❑ Yes �{�lo Inspection Other Than Rough-In:�teady Now � Will Call
�/�Q� You must call the inspector when ready! Date Ready: �� y��"j��
f �
I certi(y that I am the,�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address City
°7�Z /� � /e�e •ci l,�/� L � .%y'✓ ar�� -
Township S on Range Fire No. Counry
�pant Name
� e.�.�
tllKy
�—
'CompanyD
L- �
Iress (Conha
.�� _
� i� �
Electrical UtiIKyAddress
r
Contrador
or
�
P�s)
'rovide Two (2) Phone Numbers I
S'7�-� �'� )
Master EIeCtllcian or POWBr Llmrtetl I ecilniclan
��fmr����
/��..� <Sj'��;Z
ro (� Phone Numbers Including Area Code
��� (�►'-a)S�G� �8
EB-00001A-15 8.1.2004