P - 77623REQUEST FOR ELECTRICs4)L IN ECTION ��'��
I Q Minnesota Board of Electricity_ �5�� �% � � �
�' � V��- 2 5 3 0 1821 University Avenue Suite S-128, aint Paul, Minnesota�5904 �" �
(651) 642-0800 TTY/MR =8� 0-627 3529 www.electricity.state.mn.us �?<�gs�
Des�ribe -using the back f the white copy'rf necessary - the work cove�r dby this r ue .^
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✓ICES / POWER
0 to 400 Ampere
Traffic Signal Standard
Supplemental Fee @ $
Transformers uo to 10 I
0 to 200 Am re $5 / t ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere $10 Includes the Service andlor Power Supply up to 500 Amperes, All
tM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
;UITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Trips $20
Each S stem Device orApparatus $.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reinspection Fee $20
fIFAMILY DWELLINGS PER UNIT TOTAL FEE
3 to 12 Units @$50 Per Unit (minimum total fee is $20) • c�
Eaeh Additional Unit @$25 rHis naen FoR �NSaecTOa use crav
I hereby certiry that I inspected the electrical installation described herein on the dates stated: �
Center Pivot Irrigation Boom @
Manufactured Home Park Lots
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Se arate Bondin Ins ion $20 `"�� �" — �—� 7—�` S
Sp2C1811f1Sp2C110f1 $30 pCf HOUf emiaEOinanHOONeo onTe
S ecial inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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18812537
°1 Rough-in Inspection Required? ❑Yes_( 0 Ng/ Inspection Other han ough-In w'r�Will Call
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You must call the inspector when ready! Date Ready:
I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request in pection of the electrical work at:
Jo Site Addre � � C'
T nship � Section Ranpe Fire No. Countv
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Name -, /� Contr�q rL�cense Number Master ElecVician or Power Limited Technician
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