P - 771321 O J� `5 41 REQUEST FOR ELECTRICAL, INSP TION
� a� Minnesota Board of Electricity O(��i���-�j j�% �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55fW !
(651) 642-0800 TTY/MRS 1-800-627-3529 www.e icity.state.mn.us
Describe -using the back of the white copy if necessary - the work covered by this request: �
� o h
\ �
GENERAL FEES Outdoor L' hting Stan rd $1
SERVICES I POWER SUPPLIES Traffic Siqnal Stan (� $5
0 to 400 Ai
401 to 800
Above 800
ALARM, COMMUNICATION, REMOTE CANTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL fEES
Liahtina Retrofit na $.25 cer Fixture
spection $30 per Hour
spection @ $.31 per Mile
ALLATION MAY BE ORDERED
I lill II lil Ill�i II lil II II1 II III II III II III a� I�
L 8 5 6 5 4 1 6
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
�ncludes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiqative Fee
TOTAL FEE
total fee is $201
I herebvi certi(v that I insoecled the elecVical installation described herein on the dales stated: �
; Z-c _ e� I
�NECTED IF NOT COMPLETED WITHIN 12 MONTHS _
B ;-,.,w. .F<.:'r
�. �= cK'
, r� �f -
Date: Rough-in Inspection Required7 ❑ Yes Inspection Other Than Rough-In: ady Now 0 Will Call
You must call the inspector when ready! Date Ready:
I certify that I am th�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job SRe Street Address r � c t CdY • c`
Address
�..J • _
rPlease Provide Two (2) hone Numbers Induding
� �1 �'D��� `
ElecVical Address
Contractor License Number M r Electrician or Power limi
i n �
ny or ner Perfo ing Ins Ilation) �
`
r Own ortning In II ion) Please Provide T (2) Phone Numbers Including
. I_
� /�)
^nov wnnan n� Fi FcTainrv r.nvv Fa_nnno�