P - 76296' REQUEST FOR ELECTRICAL INSPECTION
1�� 7�- 5 4 4� Minnesota Board of Electricity _'• ;
- 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
° (651) 642-0800 TIY/MRS 1-800-627-3529 www.edectriciry.state.mn.us
Ciesa�e -usi� the back of the white copy'rf necessary - the work covered by this request:
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GENERAL fEES Outdoor Lighting Standard @$1
SEI{VIC S I PONIER SUPRLIES Traffic Signal Standard @$5
0 to 400 Ampere $25 Supplemental Fee @$20
401 to B00 Arn re $50 Trensfarmers u to 10 KVA $10
Ahove 800 Ampere @$75 Transformers over 10 KVA (a� $ 20
)MMUNIGATION, REMOTE CANTROL,
CIRCUITS OF LESS THAN 50 VOLTS
ivstem Device or Aooaratus na $.50
Addttional Unit
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Tvro Inspection Trips Each Dwelling Unit @$80
Additional Ins 'on Tri $ZO
Investigative Fee
Reins 'on Fee @ $20
TOTAL FEE �a ��
(minimum total fee is $20)
THISAREA FOR AVSPECTOR USE OA4V
I hereby certlfy that I inspected the electrical instellaGon described herein on Ne tlams spted:
Se e Bondin Ins ction $20 C, � 4�---- ��'? j•- �
SpeCIBI IOSpeCtion @$30 � Hou� E"P�01Aa4N0°"m oAre
Special Inspection $.31 per Mile
TH�$ INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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���� REC'D JUN 14 200�
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I"�°' Rough-in InspecUon Requiredl ❑ Yes � No InspecGon Other Than Rough-In: ❑�Readq Now � Wlll Catl
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I�b% �. �: /�� � You must cell 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 Ciry
65?9 CLOVE�' F'L tdE F�aIDLEY9 f�h!
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I�a�n�P I Section I Ranae I Fire No. —I coum�r��"� �Q-
Two (2)
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Electrical Utility Electrlcal Utility Address
XGEL EhIEF:GY
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pMractor / Company Nama Contractor License Number Master Electrician or Power Llmfted Technician
Llcense Number
HUI�T ELEGT�:IC CDF�F'df;�iTIOhI C,� cjc)�8,:,
Maiting Addfess (Contractor, Company or Owner PerFortning Installatlon)
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Atkharlagd Slgnetu�e (ConVactor or Owner Performing Installetion) Please Provide Two (2) Phone Numbers Including Area Code
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