P - 77407REQUEST FOR ELECTRICAL INSPECTION ��"�'�
� � �-2 � � 0 � o � Minnesota Board of Electricity �C (js - (�� /�� �- �
1821 University Avenue Suite S-128, Saint aul, Minnesota 55104
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(651) 642-0800 TTY/MRS 1-800-627-3529 www.e[ectricity.state.mn.us ���;�i�
Describe -using th� k of the white copy if n�essary - the work covered by this request:
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GENERAL FEES Outdoor Lighting Standard $1
SERVICES I POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere an $25 r�h SIIf10IP.rtIP.OTAI FPP n PDO
IMMUNICATION, REMOTE CONTROL
CIRCUITS OF LESS THAN 50 VOLTS
>VStem Device or Aaoaratus Ca� $.50
MULTIFAMILY
3to12Ur
al Unit @ $25
OTHER ADDITIONAL FEES
it @ $.25 per Fixture
rigation Boom @ $40
Home Park LoGs (d $25
ecial Inspection @$.31 per Mile �
INSTALLATION MAY BE ORDERED D
� ���� �� ��� �� �I� i� �II �) ��� �� ��� �� ��� �� ��� �� ��
18220608
� Transformers over 10 KVA @$ 20
� Transformer / Power Supply for Signs I Outline Lightinq .$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 Insoection Trios (� $20
TOTAL
total fee is
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I hereby certify that I inspeded the electrical installa6on described herein on the dates slated:
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:D IF NOT COMPLETED WITHIN 12 MONTHS
Date: Rou h-in Ins ection Re uired?
n /7 9 P q ❑Yes No Inspection Other Than Rough-In: ❑ Ready Now Will Call
/`�X�/�_J 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 h,
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I Electncal UL6ty ElecVical UtilRy Address
Standard Electri
g Address (Contracror, Cy� pany or
2672 Ma�1gG►nnd �
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N�ease Provltle Two (2) Phone Numbers Induding Are
(�s� �s�-a7p7 ( )
C,�l �
ise Number Master Electrician or Power Limited
License Number
�51) 484-8044 i )