P - 77308�srT�s�
1 8 4� 14 4� REQUEST FOR ELECTRICAL INSPECTION ,`� -����
s � Minnesota Board of Electricity k�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� `� �
(651) 642-0800 TTY 1-800-627-3529 www.electricrty.state.mn.us ���
Describe -using the back of the white copy if necessary - the work covered �. ues
�J�r � /'
GENERAL FEES Outdoor Lightin Standard $1
SERVICES / POWER SUPPLIES Traffic Signal Standard $5
IALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Apparatus (�a $.50
Additional Unit @
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irrigation Boom @ $4C
Manufactured Home Park Lots an $
Special Inspection $.31 er Mile
THIS INSTALLATION MAY BE ORDERED D
( I� II III � I�� II III (I �I� II III I) III II III II � I�
1 8 4 8 1 4 4 0
Supplemental Fee a $20
Transformers u to 10 KVA a$10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / Outline Li htin $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
TOTALFEE
total fee is $201 Z
I hereby certify that I inspeded the eledncal installa6on descnbed herein on the dates stated: �
�----�I� ` .�
OA1
WITHIN 12 MONTHS
. � 6S .'� � �
�
ua�e: Rough-in Inspection Required? ❑Yes �fJo Inspection OtherThan Rough-In:�eady 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 Address Cdy nC ��
� r��
Township Section Range Fire No. County
Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
�
L �li �
Maili ress (Contractor, Company or Owner Per1
Authorized Signature Contractor or Owner erf
INSTRUCTIONS ON BACK OF YELLOW COPY
Utility Address
� I ��
BOARD OF ELECTRICIN COPY
\ /
masier eiecmcian or
License Number
Two (2) Phone Numbers InGuding Area Code
-6�0 ( )
FR-OOOOtA-iCi R'I �nna