P - 76414REQUEST FOR ELECTRICAL INSPECTION �
a Minnesota Board of Electricit � � �
2�� v�� Y� ��� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 k '�
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(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us ��s
Describe -using the back of the whfte copy if necessary - the work covered by this request:
�' r� o�t- C.G f rt'0� � Zoa
GENERAL FEES Outdoor Lghti Standard $1
SERVICES I POWER SUPPLIES �5 Traffic Swnal Standard (� S5
Above 800 Am ere a$75
CIRCUITS / FEEDERS
0 to 200 Am ere a$5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CANTROL, SIG
CiRCUiTS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMIIY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Add'Aional Unit @ $25
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Supply for Si ns / Outline Lightinq $5
ONE & 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
dd'Rional Inspection Trips � $20
Investigative Fee
Reinspection Fee na $20
TOTAL FE j I Qs'
total fee is $20 /Zf
� rteuunt a y.co per rixiUre I hereby certi(y that I inspected the elecUical installation desaibed herein on the dales stated:
Pivot Irri ation Boom $40 RWGMIN pA,�
ctured Home Park Lots $25 �- 2 m
tional Vehicle Park Sites $5 F�NA� �NSa�cT N� onTe
te Bonding Inspection @$20 J/�..C.c.._►. 3%,� _ U°/
Special Inspection $30 per Hour E%PIREDIN6INDONED pA
Speciallnspection $.31 rMile
� i i�ii� iiv5 i AL�qTIVN NIAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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2�369971 ��U� �G'��
Rough-in Inspection Required? �Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call
1�Z� �� You must call the inspector when ready! Date Ready
I certity that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work ai
Job Site Street Address ��,
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Township Section Range Fire No. CounN
sw. /�.r
Electrip Utility Utility Address
�XCeI �'IC S
Contrador / Company Name on6
G1 � C
Mailing Ad ess �( ontractor, Company or Owner Pe rming Installation)
7a i2 � ` 1
Author¢ed Signature (ConVador or O er Performing Instaliation)
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INSTRUCTIONS ON BACK Of ELLOW COPY BOARD OF ELECTRIC
(7t� 717-97! 7 ( )
lylPl.� „�c�
�se um r Master Electncian or Power Limited Technician
� � � � License Number
1
ti . .SSas.6
P ease Provide Two (2) Phone Numbers Including Area Code
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FR.(IMI(1tA_15 a 1 �lMe