P - 77700Q/� REQUEST FOR ELECTRICAL INSPECTION ��""�
��� C3 �F �= 2 5 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
Describe -�sing the back of the white copy if necessa - the work covered by this request:
�EPf�'I (Z T -iz� ��� .
GENERAL FEES Outdoor Li hting Standard $1
0
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or paratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighting Retrofd $.25 per Fixture
Center Pivot Irtiqation Boom (� $40
Special Inspection a$30 er Hour
S ecial Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED D
I IIII II II) II III I� III I) III II II� II (II I� III �� I�I
18422535
Traffic Signal Standard $5
Sup lemental Fee a $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UN�T
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Addftional Ins�ection Trios kil $20
TOTALPEE
total fee is $20) �0 .��
I hereby certity that I inspected the electncal installation described herein on the dates stated: I
`�--______� b'� _
IF NOT COMPLETED WITHIN
_ __
"Q. Rough-in Inspection Required? ❑Yes ❑ No Inspection Other Than Rough-In: ]� Ready Now � Will Call
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You must call the inspector when ready! Date Ready:
I certify that I am the L,�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Street Address n -,, - City,`,
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or Owner Performii
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BACK OF YELLOW COPY
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�I Utility Address
Contractor License Nurr
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Installation)
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�Ilation) Please i
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BOARD OF ELECTRICITY COPY
Numbers
\ /
Master ElecVician or Power Limited Technician
License Number
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�o ( Phone Numbers I�Guding Area Code
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EB-00001A-1 N t ?fIM