P - 765611 7 81 9 2 3 6 REQUEST FOR ELECTRICAL INSPECTION �
� � Minnesota Board of Electricity ;�Y� ` '
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -
(651) 642-0800 TTY/MRS 1-800-627-3529 x>ww.electricity.stale.mn.us
Describe -using the back of the white copy if necessa - the work covered by this request:
F XC� i_ E.hIE�:f:'�'i' �t1�J��i ' �i �I']:1"i,i-I
GENERAL FEES Outdoor Lighting Standard
SERVICES I POWER SUPPLIES Traffc Sinnal Standard n 9
800
CIRCUITS I FEEDERS
0 to 200 Ampere @ $5 -� �
Above 200 Ampere @$10
ALARM, COMMUNICATION, REMOTE CONTROt
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL I
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit fc� S25
Boom
Home
Supplemental Fee @ $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns I Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
Fee
Fee
iviw�rtt L�.�G
total fee is $20)
that I inspected the electncal instailation descnbed herein on the dates stated:
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Special Inspection $.31 per Mile
THi5 INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Rough-in Inspection Required? ❑ Yes 7�] No .; Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
You must call the inspector when ready! I Date Ready:
I certify that I am the L•XJ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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Township Se tc ion Range �Fire No.
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j OwnerlOccupant Name Please Provide
�HC�LTIiARL� FVEL i'!�! iYl �, � �
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Electrical Utility �, Electrical Utility Address
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i Contractor / Company Name � � Con[ractor License Number
I HU�iT ELECTEiT.0 �OFiF'OF:fiTIOh! !.-:(�� �1Cx�;8;
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'�� Mailing Address (Contractor, Company or Owner Performing Installation)
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Numbers Including
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Master Electrician or Power Limited Technician �
License Number
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� Autho� Si nature (Contractor or�Owner Performing Installa[ion) - I�I`Se �� ro� ��wo�� j hine Numbers ��
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INSTRUCTIONS ON BACK OF YELLOW COPY BOARD OF ELECTRICITV CoPV