P - 76228REQUEST FORR�LECTRICAL INSPECTION
i �� � � � � 4 � � � Minrtesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-0800TTY/MRS 1-800-627-3529 www.electricity.state.mn.us ��� '
Desaibe -using of the whit copy' - vrork covered by uest:
..�" .�f�f�Da��
GENERAL FEES Outdoor Liahtina Startdard Ca� $7
)MMUNICATION, REMOTE CONTROL,
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Aooaratus C�a $.50
Ughting Retrofit (a� $.25 per Fixture
Cerder Pivot Ir�gation Boom @ $40
ManuFactured Home Parlc Lots $25
Recreabonal Vehicle Paarlcc Sitas $5
Se Bond I� 'on $20
Special Inspectlon @ $30 r Hour
S ' Ir�speciian $.37 per Mle
THIS INSTALLATION MAY BE ORDERED [
II�I����i�Ilillalllll�O�IIIlaO�l�
1820461�
Transformers up to 70
Transformers over 10
Includ�s the Service andlor Power Supply up to 500 Amper�, AO
Circuits and Tvro Inspection Td� Each Duvelung Unit @$8
� Fee @ $20
TOTAL FEE �
inimum total fee is $20)
TXL4 A�A FINt U�ECfOR USE OtLLY
�
I Nspeded the electrical ir�tellaUon descnbed tiere
INECTED IF NOT COMPLETED WITHIN 12
FOk' 6FpICE USE ONL'f
z��������
�s�i
date.s
�.
�f �i`f-�? �
"""'' Rough-in Inspectlon R 1�? ❑Yes ❑No Ins
equ pec�on Ofher Than Rough-In: � Ready Now 0 Will Ca0
You must caq the inspedor when readyl Date Ready.
I certify that I am the 0 UCENSED CONTRACTOR ❑ COMPANY j�OWNER and hereby request inspection of the electrical work at
Job S(te Street Address /� Cryy
��19 I a�i1/JAr�'1i�J JT /�� �! ULL�
/��1�
Plea� Provide Two (2) Phone Numbers Im�udirtg Area Caie
(��/ �53 � (3�3��z :3.5so
nse Number Master Electridan or Power Limfted Techn
License Number
Please Provtde Two (2) Phorre Numbms IncludU�g Area Code
� � � �