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P - 77017REQUEST FOR ELECTRICA� INS,eECII �� 1QQ Minnesota Board of Electricity p(�,S '�/ ��, �� s.I �J ��- 5 7 5 � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 `� � 'll_ (651)642-0800TTY/MRS 1-800-627-3529 www.electricity.state.mn.us �� d"�P Describe -using the back of the white copy if necessary - the work covered by this requ t: � �l�no��r7y, c�2 ��o Q-i2� ?�Cii�'PCYhIP ��4�2 S`�t1Yi'� ��9.9�Q� �- Yw 0..5�— � SERVICES / POWER SUPPLIES 1 0 to 400 Ampere l�a $25 ALARM, COMMUNICATION, REMOTE CONTROL, SIG CIRCUITS, CIRCUITS Of LESS THAN 50 VOLTS Each System Device or Apparatus @$.50 ADDITIONS TO THE GENERAL FEES Fee @ $20 up to 10 KVA @ $10 over 10 KVA na $ 20 Includes the Service and/or Power Supply up to 500 Amperes, All � Circuits and Two Inspection Trips Each Dwelling Unit @$80 Additional Ins ection Tri s $20 Investi ative Fee Reinspection Fee (a� $20 fIFAMILY DWELLINGS PER UNIT TOTAL FEE ��. �°� 3 to t2 Units @$5o Per Unit (minimum total fee is $20) Each Additional Unit @ $25 rwsaaenroRiNSPecroauseaar r►11� �t - zr a3' OTHER ADDITIONAL FEES Liohtina Retrofit (� $.25 oer Fixture i herebvi certifv that I insoeded the electrical installation described herein on the dates stated: Center Pivot Imgation Boom Manufactured Home Park Lc �o� 3 --� Special Inspection $.31 per Mile THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS ___� � �I�� (�� L8955757 uace:l Rough-in Inspection Required? ❑Yes �lo Inspection OtherThan Rough-In: �'f%ady Now ❑Will Call ` q^i Z.? j You must call the inspector when ready! Date Ready: I certify that I am the LICENSED CONTRACTOR p COMPANY ❑ OWNER and hereby request inspection of the electrical work at: Job Site Street Address City � �o � �'�e� 0� `��'"�. N � � l C� � ------- - � -----� - � ----- � -PL�Y1'c � 1 S 1�D YLS Mailing Address (Contrador, Co any or Owner P or ing Inst� ��o �� -�� I Authorized Si - �re (Contr3dtor or Orm r erformino Installat ��) a�-'3�°t� ) License Number Master Electrician or Power Limited Technician I �� -� License Number 2�ne Num�lud�� LS3 ( )