P - 77029REQUEST FOR ELECTRICAL INSeE�T.�O �`�
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I � � g � a � � n � Minnesota Board of Electricity �/� — ( bi �� �-Q
[ 1821 University Avenue Suite S-128, S in �aul,'jinnesota 5 104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white co y'rf necessary - the work covered by this request:
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GENERAL FEES Outdoor Li htin Standard @$1
SERVICES I POWER SUPPLIES Traffic Sianal Standard (o� $5
0 to 400 Ar
401 to 800
Above 800
I CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Liahtinq Retroffi (ai $.25 cer Fixture
Park
Transformers over 10 KVA $ 20
Transfortner I Power Supply for Signs I Outline Lighting @$5
ONE 8 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
total fee is $20)
I hereby certify that I inspec3ed the electrical installation described herein on ihe dates stated: �
Speciallnspection $30 rHour ""'"h°'""" �=
Special Inspection @ $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT
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1 8 8 6 1 6 2 5
JIPLETED WITHIN_12 MONTHS
uate: Rough-in Inspectian Required? ❑Yes � Inspection OtherThan Rough-In: ❑ Ready Nq��]Will Call
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_ f You must call the inspector when ready! Date Ready:
I cerfify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address City
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Township Section Range Fire No. County
Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
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�;ontractor or Owner Performing Installatlon)
ConVactor Lice�se Number Master Electncian or P
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Area