P - 77529(� REQUEST FOR ELECTRICAL INSPECTION
� � s J 6�� 3� 3 � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
__ (651) 642-0800 TTY/MRS 1-800-6273529 www.electricity.state.mn.us
Describe -using e badc of the ite copy 'rf necessary - the wo covered by this uest: _
/ICES / POWER SUPPLIES
0 to 400 Amcere na $25
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lightin Retrofit $25 per Fixture
Center Pivot Irriqation Boom (o� $40
5 ecial Ins ection $30 er Hour
Special Ins ion $.31 r Mile
THIS INSTALLATION MAY BE ORDERED
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19633536
Traffic Siqnal Standard
� Transformers over 10 KVA @$ 20
� Transformer I Power Supply fw Sipns I Outline Liphtinq $5
ONE 8 TWO FAMILY DWEILINGS, EACH UNIT
InGudes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Insoection Trios a(� $20
TOTAL FEE
(minimum total fee is $20) -��'
TNIS FRE4 FOR INSPECTOR USE ONLV
I hereby certi(y that I inspected the electrical installation described herein on the dates stated:
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IF NOT COMPLETED WITHIN 12 MONTHS
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Rough-in Inspection Required? ❑ Yes ❑ No Inspection Other Than Rough-In: eady Now ❑ Will Call
��`s D C You must call the inspeckor when ready! Date Ready:
I certity that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Sde Street Adc�ress I f �, ,� CnY � %%��
Owner/OCCUpant Name
ElecUical Utility � Elech
r
ConVador / Company Name
�EPENDABLE ELECTRIC, INC.
Range Fire No. County
1
Please Provide Tw (2) hone Num rs ' g Area Code
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Iress
Contrador License Number Master Electrician or Ponw�eIr Limited T nician
/C ���� ,/'('�� i License Number �/// ( ! � 1�' (�
(_s1' ( %Y J
�aumoraea signa[u � ctor or owner Perto i g Installation) Please Provide Two (2) Phone Numbers Including Area
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INSTRUCTIONS ON BACK OF YELLOJQI.B BOARD OF ELECTRICITV CoPV � co rv�nn� n. c