P - 77553REQUEST FOR ELECTRICAL INSPECTION ��"�
� 1 84� 117 � �
� � Minnesota Board of Electricity � ;�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �..' '
� (651) 642-0800 TTY/MRS 1-800-6273529 wwtiv.electricity.state.mn.us ��?
Describe -using the back of the whi y if necessary - the work covered b thi quest:
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GENERAL FEES utdnnr I inh mn Stanrinrrl �l A1
/POWER
Above 200 Am ere $10 �
ALARM, COMMUNICATION, REMOTE CANTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Irrigation Boom
1 Home Park Lc
Vehicle Park Si
edal Inspection @$.31 per Mile �
INSTALLATION MAY BE ORDERED D
I IIII II II) II II) II III (l III II III II III II III ��I I NN
18421L72
Traffic Signal Standard $5
Supplemental Fee $20
Transformers u to 10 KVA a$10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / 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
Additional Inscection Trios na $20
(minimum total fee is $20) ' Q �`�
THIS AREA FOft INSPECiOR USE ONL
I hereby certi(y that I inspected the electrical installafion described herein on the dates stated:
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IF NOT COMPLETED WITHIN 12
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� Rough-in Inspection Required? ❑Yes �o Inspection Other Than Rough-in: 0 Ready Now Will Call
�� o You must call the inspector when ready! Date Ready
I certify that I am the�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site SVeet Address
City
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Township Section Range Fire No. County
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actor/Company �,�ka� MN 55304
7��-757-6202
g Address (Contractor, �ompany or Owner Performin�
�rued $i ture (C tract r rming In:
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J 5 ON BACK OF YELLO Y
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License Number Master Electrician or P�
a . �/1, / License Number
� Please Provide Two (2) Phone Numbers InGuding fU
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OF ELECTRICITY COPV co nnnn. e