P - 76636REQUEST FOR ELECTRICAL INSPECTION �
I�- 9 4 3� a.D V 1 �., Minnesota Board of Electricity s- '�
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of 1he white cop�flwcessary - th ork�vered by thi quest: /' •
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GENERAL FEES Outdoor Lightin Standard $1
SERVICES I POWER SUPPLIES Tra�c Sianal Standard (a� �5
( Above 200 Am ere a$10
ALARM, COMMUNICATION, REMOTE CANTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Anoaratus (c� $.50
Additional Unit @
Lighting Retrofit @ $.25 per Fi�ure
Center Pivot Irriqation Boom (�D $4(
S dal Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDEREI
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L9435619
Supplemental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns / Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ection Tri s $20
Investi ative Fee
Reins tion fee $20
TOTAL FEE �- �
(minimum total fee is $20) ,��, J
I hereby certify ihat I inspected the electripl installatian described herein on the dates stated:
ROUGHIN DATE
F SPECTION ` ppTE
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NECTED IF NOT COMPLETED WITHIN 12
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"� /+1 gh-in Inspection Required? ❑ Ye�o InspecGon Other Than Rough-In: � Ready Nov /Jill Call
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L/ ou must rall the inspector when ready! Date Ready:
I certify that I am th LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the ele�risel work at
Job Site Street dress / � /' Cny /�
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Township Section Ranpe ire No. CounN
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Electrical Utility
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ictor, Company or Ow er Perfortnin Insta lat
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Jumbers InGuding Area Code
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Master Eiectrician or Power
License Number
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