P - 78208C(� REQUEST FOR ELECTRICAL IN�PECTION
1� J-2 3� J O� a Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTYlMRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW �REMODEL 0 ADDITION ❑ REPAIR Describe -using the back of ihe white copy if necessary - the work covered by this request:
�e �dd,`�v �Nd �I- 002 oN d�
�ENERAL FEES Outdoor Li htin Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
, 0 to 400 Amcere �$25 "1 nt c����.��rai F.a ���n
ALARM, COMMUNICATION, REMOTE CON7ROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A ratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @ S50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Li htin Retrofit $.25 r Fixture
Center Pivot Im ation Boom $40
Manufactured Hame Park Lots S2
Recreational Vehicle Park Sites $5
Se arate Bondin Ins tion $20
S i� Ins Gon $30 r Hour
S iallns 'on $.31 Mile
THIS INSTALLATION MAY BE ORDERED DI;
i iiii ii iii ii iii i� iii ii �ii i� iii ii iii i� iii � m i�
15239023
� Transfamers up to 10 KVA (n� $10
� Transformers over 10 KVA �$ 20
Transformer I Power Supply for Signs / Outline Liqhtinq (�a $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Cirouits and Txro Inspection Trips Each Dwelling Unit @$80
Reins tion Fee $20
TOTALFEE p
(minimum total fee is $20)
T��F�a���,«��SE«�.
I hereb inspec0ed Ihe mstalla6on described herein on tl�e dates stated:
+L ��P��
ROUGHIN �� DNiE
_ 3_��,
�IWLL INSPECTION DATE
-Z6- ��
� �� �
c�'�-���s� �-, . s-�
��� � Rough-in Inspection Required? Yes O No I�s
pection Other Than Rough-In: ❑Ready Will Call
��v� Vou must wll the inspecta when ready! Date Ready:
I certify ihat I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of Uie electrical work at:
Job Site Address (Street, Bo or Route No.) CitY Zp Code
� 9�3 �ek�R✓ i',���/p ��,�d/��
•_i io . •.
Xce l
Contracla / Compa
`y'i/, // �
. - ,�NQ,�g
Please Provide Two (2) Phone Number(s) I
� ,,� a _3)So3-/a� �/ )
wa�se numcer mas[er necmaan a
OO O � /� License Number
�
i
�� "� I ��3- s��/ �/9'3 I
_ ,
ON BAGK OF YELLOW COPY � U BOARD OF F�CTitICT' COPY � E&OOOOtMt� 8.1. Z002