P - 75779REQUEST FOR ELECTRICAL INSPECTION `� `�`
1����-16 9 1� Minnesota Board of Electricity .� ;
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-OS00 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the b ck ite copy'rf nece ry- the work covered by this request:
�
GENERAL FEES Outdoor Lighting Standard @$1
SERVICES I POWER SUPPLIES Traffic Sianal Standard l�a $5
Above 200 Am ere c$10
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL I
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Rer Unit
i Home Park
Vehi�le Parp
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns I OuUine LI htln $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$BO
Additional Ins ction Tri s $20
Investigative Fee
Reinspection Fee @ $20
TOTALFEE
(minimum total fee is $20) • p2jJ
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I hereby certify thffi I inspecied the electrical inslella8on describ� herein on the dates stated:
5peciel Inspection @ $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT
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'LETED WITHIN 12 MONTHS
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��e' Rough-in Inspection Requiredl ❑Yes No Inspectlon Other Than Raugh-In: Ready Now ❑Will Call
You must call the inspector when ready! Date Ready:
I cer6iy that I am the ❑ LLCENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
�on sne streec,adaress �� ��ri �
463-��2 2sa` (
ciecmca� uaucy Electrical Utllity Address
N/A JL
Contra�tor / Company Name Contractor License Number Mester Electrician or Power Limite
�OV� ��7I� i 1 /� ^. �", License Number
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Mailing Address (Contractar, Company or Ormer Perfortning Installadon)
23049 A�R�W�AD' 3T NW 3T FRANa�LI MN gS1%%�
Authorb.e�i S�ture (Contractor or Owner P ing Installatlon) Please Provide Two (2) Phone Numbers Including A
`( -"' �63-�53-Si31 '�63 �-28�
. INSTRUCTIONS ON BACK OF YELLOW COPY BOARD OF ELECTRICITV CoPV vc nnn�� n