P - 76430REQUEST FOR ELECTRICAL INSPECTION �
1� 7 8 7� 9 3 O 5 Minnesota Board of Electricity ��e�'
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -
(651) 642-0800 TTY/MRS 1-800-627-3529 wwtv°.eleclricity.stale.mn.us
pesCnbe -usirg the back of the white copy if ne,sess��-;the y�!q��C;sq,v,Q,rc� by,E�� f84�eSt: 1 r,.� �,� -r �� ��
�,,4t , .,�;
GENERALFEES
to 800
�e 800
>! FEE
ALARM, GOMMUNICATION, REMOTE CONTRO�, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
EacM System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
3 W 12 Units
25 per Fixture
� Boam an 34C
Outdoor Lighting Standard
Traffic Siqnal Standard (�o
Transformers over 10 KVA $ 20
Transformer / Power Supply for Signs / Outline Lighting @$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
Additional Insoection Trios (c� $20
Fee
TOTALFEE :r'�Ja
total fee is $20)
that I inspected ihe electncal installation descnbed herein on tl�e dates stated:
.. , . �.. W., ) 3.- G �
Se drate Bondi Ins ection ,$20 ���--���� '/ /
S I Inspection @$30 per Hour exa o; nenNCONeo oATE
Special Ir�spection $.31 per Mile
THtS lN3TALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
111 � .
u �1��I�i��ill�Nl�ll�ll�lllllllllll �`
1 7 8"� 9 3 0 5 CI U�/G�- ���
�"°"'' I Rough-in Inspection Required? ❑Yes � No �I Ins ection Other Than Rou h-In: �Read Now
i .LS^tt`1?,V'� �, P 9 Y ❑WiIlCall
'� �'�, You must call the inspector when ready! �; Date Ready:
I certify that I am the C� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
_- — ___ _ _ — - — -
� Joh SAe Stree[ Address �, City F T r t �,7 +- c: �i -� �'.
r r ii
I . !. �_ _. � i f .. �: ,:� J �x _i .:.
� :L '� � S = �. i�.l? F_
Range 'I Fire No.
i i � �. _ �- �.• �
� � - �, h i @ _� �. i'1
;__- __.__.._ _. __.__ _ .._ -'. _�— .- __._ ._. -_. _ __
I OwnerlOccupant Name ' Please Provide Two (2) Phone Numbers Including Area Code
. . . . _,: ., -
' �- ( l ( l
t C. ^•'. hi �{ i? �1`i i�: .i �..: r t.. r-� "�i �_:
I �1-ii�:1. \ / \ /
I'�— ---- --- ---------- - ------Y —_._. �
i E�ectncal UtiAty 7 Electrical Utilit Address
.'�:..�� !_�';� "''��� ���.
. i': t.7 I
I�____—.—_'_ -- -_.._....'_..�...�`' •v _�; � . ,5,.: ��t . —_ _._ :�
Confractor / Company Name �, Contractor License Number Master Electrician or Power Limited Techni�
j-;i,;4i"(' r.{...i_�: ! 1? 1.tr.. '.�`�.�- l�!'1l�i s�.! F; i.,G} (j�,?an.j LicenseNumber
- - _ �
AkaUing Address (Contractor Company or Owner Performing Installation) --� � � �
-r._� � _ r
.._.:7'.`'=! l�.:�.�;.,.it�tt..i.,1L.. hi�1i.�ly `.:i�t�.i��� i'ii{._�i..�� i�.r �3i=�1,'Li
�- --- - - - � - - -- - -- . _--- . _.__. _. - -- --
Authn[itQd Si nafure (Contrector or Owner Performing Installation) �-� �'�, Please Provide Two (2) Phone Numbers Including Area Code
' - � : �-:;-� � /
7� �
�(t :}� tjl1-,_..; - t 1 �
-- ---_....--- ----- --- -- - - --.—: ,
INSTRUCTWMS ON BACK OF YELLOW COPY BOARD OF ELECTRICITY COPY FR-nnnmA-15 a � �nna
I
;