P - 76607REQUEST FOR ELECTR�CAL INSPECTION
1- 5 4 7- 3 2 5� Minnesota Board of Electricity ���s _���
1821 University Avenue Suite S-128, ai aul, Minne 510
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electricitystate.mn.us
/
❑ NEW MODEL ❑ ADDITION O REPAIR Describe -using the bxk of the white copy 'rf necessary - ihe wak cov�ed by this request:
Outdoor Lighting Standard
Tralfic Siunal Standard �
�l Am e ab ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
200 Am e S10 Includes ihe Service aridlor Power Supply up to 500 Amperes, All
IMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit Q S80
CIRCUITS OF LESS THAN 50 VOLTS ann�s�,� i��,� r�,� ca t�n
ADDITIONS TO THE GENERAL FEES Reins tion Fee E20
fIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units � a50 Per Unit (minimum total fee is $20)
Each Addi60n21 Unit Q t25 ries,w� wrs rarecroa us� «ar •
I hereby catiy tl� I inspeckd the elxYical i�taNa4on despibed herein on the da0es staEed:
OTHERADDITIONALFEES ��-c�„x, Ct�+.-�, �3q�'4
Lighting Retrofit � $.25 per Fixtute
Center Pivot Irtifl�on Boom 0 f4(
���
IF
illll IIIII IIIII 1161 IIIII II III II III NIII �� I�
15473259
--! 3 �J
MiE
.7t �3 f a�
_ , . y_��_��_
7/%� v�� r�n;o ir,s�eaan �u�redz � ves ❑ No Inspection Otl�er Than RougMn: OReedy Now � WNI Call
You must call the inspeda when ready! pe�e R�y:
I certi(y that I am the UCENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of the electrical work at: