P - 77654REQUEST FOR ELECTRI AL INSPECTION �
I 1� v� ��� g 3 7� Minnesota Board of Electricity �� S-��,�j �- �
1821 University Avenue Suite S-128, Sain-t Paul, Minnesofa 55104 �
(651)642-0800TTY/MRS 1-800-627-3529 www.electricity.state.mn.us ��' `
Describe -using the back of the whfte copy if necessary - the work covered by this request:
o�.�'r ��i�O� �' r?2 L�'/d �L,� D�L
GENERAL FEES Outdoor Lighting Standard $1
SERVICES I POWER SUPPLIES Traffc Si nal Standard @$5
0 to 400 Ampere $25 — Sup lemental Fee $20
401 to 800 Am ere $50 � Transformers u to 10 KVA $10
Above 800 Am ere $75 Transformers over 10 KVA $ 20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li htin $5
0 to 200 Am ere $5 ONE �TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere $10 udes the Service and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONT OL, SIGNALIN Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOL Additional Inspection Tri s $20
Each S stem Device or Apparatus $.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ion Fee $20
MULTIFAMILY DWELLINGS PER UNIT TOTAL FEE
3 to 12 Units @$50 Per unit (minimum total fee is $20) ��! ��
EeCh Addlt10f121 Unit (� $25 nns a�a Foa nuaECroa use aeir
I hereby cedify that I inspected the elecUical installation desaibed herein on ihe dates stated:
i Home Park
Vehicle Park
�r �- //%'O J
spection @$.31 per Mile � �
ALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12
�III) IIIII O III I) II) I�III I�III IIIII III�� �� I�
1839937g
Rough-in Inspection Required? ❑ Yes [y�JO Inspection Other Than Rough-In: �Ready Now ❑ Will Call
/� / �
` �i �� You must call the inspector when ready! Date Ready:
I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address ��Y
3.�1 ��=�.c�,� �,�-�i �,�„�. o �.
`
��
� �� �.-� �. (�6� 3�0.�0 ��4 )
_ _ Electncal UtilitvAddress
Name Cantractor License Number Master ElecVician or
�� /+ `� _ � � ,/J D � )� � License Number
�T�I��' �iC.� ff� !
5ctor, Company or Owner Perfortnm InsTallationl
�S'1-121�- )