P - 76538;- REQUEST FOR ELECTRICAL INSPECTION
� � � � � � 9 � 6 ,, Minnesota Board of Electricity �-.-�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
��''t 15 (651)642-0800TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the�of the white cqpy if ecessary - the work covered by this request:
U�C� �, C,�.�:�0 ' _' —�S
GENERAL FEES Outdoor Li hting Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere $25 Su plemental Fee $20
401 to 800 Am re $50 Transformers u to 10 KVA $10
Above 800 Am re $75 Transformers over 10 KVA $ 20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns I Outline Li htin $5
0 to 200 Am ere $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere $10 Includes the Service and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CANTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Insoection Trios C� $20
Each S stem Device or Apparatus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unft
Each Add'Rional Unit @ $25
OTHER ADDITIONAL FEES
i' ti Retrofit $.25 per Fixture
Center Pivot Irriaation Boom C�D 840
S eciai Inspection $30 per Hour
Special Inspection @ $.31 per Mile
THIS INSTALLATION MAY BE ORDERED
�IIII IIIII II (II II (II II III IIIII IIIII IIIII �� InN
19299668
TOTALFEE
total fee is $20) � � � ��
I hereby certity that I ins�cted the elecUical installation described herein on the dates sWted:
RWGH IN pp�
FINALINSPECTION �`, _ OATE
�-- `��. ,/� b-C�
IF NOT COMPLETED WITHIN
. _ _ 1�FIC�� .. ;� ii!':'_.
Raugh-in Inspection Required? ❑ Yes �Mo Inspedion Ofher Than Rough-In: ❑ Ready Now �will Call
�z '�z �a� �v '�
You must call the inspector when readyl Date Ready:
I certify that i am the J�`LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elecVical work at
Job Site Street Address ��,
+'C,�a��-f �rre��e /1%� �r��l-ee�
��/1Vl �O '�'ti
�d��y Electrical Utility Addtess
� c� 13562 Cbntral Ave' NE �
iress (Co , a r ortning Installatlon)
7v3- 7-620�
i Signatur�i (Contra r or . er{� : g Installation) ,
.� �%� ✓ � ��`' �f �
/ .� ,6'' �� � i
)NS O�BACK OF YELLOW COPV�s � annRn nc ci Fci
6�3)���- qa3� ( )
nse Number Master Eleatricien or P
License Number
Please Provide Two (2) Phone Numbers I
` / \ �