P - 77528REQUEST FOR ELECTRICAL INSPECTION
1� 1 V 1- 9 3 7 0❑ Minnesota Board of Electricity �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 ''�. .
(651) 642-0800 TTY/MRS 1-800-627-3529 ti��o�r.electricitv.slale.mtt.us
Descnbe -using �he back of the white copy if ne s ar�-�the r.�4ve�.e� by.t�i� �g�u�st; ,-. �.� •• i3
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SUPPLIES
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401 to
Above
;UITS I
NNMUNICATION, REMOTE CONTROL, SIG
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Apparatus @ $.50
ADDITIONS TO THE GENERAL FEES
Z Units @ $50 Per Unit
Additional Unit @ $25
OTHER ADDITIONAL FEES
�g Retrofit @ $.25 per Fixture
r Pivot Irriqation Boom (a� $40
,
Traffic Signal Standard @ $5
Supplemental Fee @ $20
Transformers u to 10 KVA ,$10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trios la� $20
Fee
TOTAL FEE •,'.'t i p ;�ii
total fee is $201 �
that I inspected �he electrical installation described herein on the dates stated: �
ate Bondin In tion $20 �/ 3— �` %
S al lnspection $30 per Hour emiaeo aenNOONeo oATE
S eaal Inspection @$.31 per Mile
HJS MISTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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L°"'. Rough-in Inspection Required? ❑ Yes �] No I Inspection Other Than Rough-In: QReady Now ❑ Will Call
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� _ You must call the inspector when ready! j Date Ready:
I certify that I am the L�] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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I Job Site Street Address .---- Cit ="� r"' �- .r. �y-:':'.
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! Owner/pccupant Name
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Section �i, Range I, Fire No.
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Please I
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>ne Numbers Including
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;�^ ���ra��r �� c ��� contracror License Number ' Master Electrician or P
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� iling Address (Contrector, Company or Owner Performin� Installatio � ' � - . �� � -
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iit�iz2d 3' nature (Contractor or Owner Performing Installation) ,, Please Provide Two (2) Phone Numbers I
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�NSTRUCTIONS ON BACK OF YELLOW COPY � BOARD OF ELECTRICITY COPY
Technician I