P - 76617REQUEST FOR ELECTRICAL INSPECTION ��
2�� 5��„ 3 4� � Minnesota Board of Electricity � p,
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 ��'
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us �;�s�
Describe -using the ck f the white copy if necessary - the work covered by this request: �?��
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� SERVICES / POWER SUPPLIES
0 to 400 Amcere a(� $25
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or A paratus $.50
ADDITIONS TO THE GENERAL FEES
Center Pivot Irrigation Boom @
Manufactured Home Park Lots
Recreationai Vehicle Park Site:
THIS INSTALLATION MAY BE ORDERED I
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20593463
Traffic Signal Standard
Supplemental Fee @ $
Transformers up to 10
Transformers over 10 F
Includes the Service andlor Power Supply up to 500 Amperes, All
Circutts and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ection Tri s a$20
Investi ative Fee
Reins ection Fee $20
TOTALFEE
(minimum totai fee is $20) ��-
I herebv certifv that I insoeded ihe elecUical installation described herein on the dates stated: I
IF NOT COMPLETED WITHIN
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uaie: Rough-in Inspection Required? ❑ Yes i��JO Inspection Other Than Rou h-In:
7 g Ready Naw ❑Will Call
`� i� �sv�i You must call the inspector when ready! Date Ready: 1������
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
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Address (COntractor, Company or Owner PerfortnN9
or
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r License Number Master ElecUician or Power Limited Technician
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Please P vide Two (2) Phone Numbers InGuding Area Code
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