P - 76378REQUEST FOR ELECTRICAL INSPECTION '��
��QQ(� Minnesota Board of Electricit `�� w
J.J 4:J '`3-� 4 3 7� �gZ� University Avenue Suite 5-128, Saint Paul, Minnesota 55104
� k �� �' (651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us ?�
Describe -usi e back of they� e py if necessary - the work covered by this request:
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GENERAL FEES Outdoor Lightin Standard @$1
SERVICES I POWER SUPPLIES Traffic Si nai Standard $5
0 to 400 Amaere an $25 ,.� Supplemental Fee @$20
Above 200 Am ere a$10 '
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus $.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITI01
Lighting Retrofit @ $.25 per Fixture
Center Pivot irriaation Boom (� $4C
� Transformer I Power Supply for Signs I Outline Lighting @$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
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total fee is $20) 0�6
I herebvi certiN that I inspected the electrical installation described herein on the dates stated:
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Special Inspection @$.31 per Mile � �
IIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12
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Date: Rough-in Inspection Required? ❑ Yes No Inspection Other Than Rough-In: ❑ Ready Now Will Call
��� �� 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 Adtlress City
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Township Section Range Fire No. County
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Electrical Utility Address �
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�� Contractor License Number Master Electrician or P�
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AUthOfized _$fgl tUfB (C fitfeCt f O��rtning Install8ti PleaSe P�OVitle TWO (1) F'h0t12 NURIbBfS I
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