P - 79779� REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
�-396-�J37 � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -
(651) 642-0800 TTY/MRS 1-800-627-3529
www.electricity.state.mn.us ' �
IdentiTy the work covered by this request:
C7 NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR XGEL ENEROY SAVER�S SWITGH
0 to 400 Am ere �$25
401 to 800 Am ere �$50
Above 800 Am re � $75
CIRCUITS / FEEDERS
0 to 200 Am ere (� $5
Above 2p0 Am ere � $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
.TIFAMILY
�
Li htin Retrofit �$.25 er Fixture
Center Pivot Irtigation Boom � $40
ManOfactured Home Park Lots � $25
Recreational Vehicle Park Sites � $5
Se rate Bondin Ins ection �$20
S ecial In 'on �$30 er Hour
S ial Ins ection �$.31 er Mile
� HIS u'�__ _ -_+•-.,..v-.BE ORI
I I�If� �� �II� III� ��III
IIIII IIIII I�I�I IIII ��I�
'` 1 3 9 6 5 3 7 1*
Yes
Transfortners u to 10 KVA �$10 '
Transformers over 10 KVA � $20
Transfortners / Power Suppty for Signs / OuNine lighting �$;
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Suppiy up to 5� Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unil �$80
Additional Inspection Trips � $20
f011 INSPECTOR USE ONLV
I hereby [
ROU6H IN
TOTAL
DATE
^ � DATE
C -� 3 `z? �
yOT CC�MPL��^ITHIN 18 MONTH
FOR OFFICE USE ONLY
�22� �° �'�
�,��
>n Other Than Rough-in: Ready Now ❑ Will Cal,
You must call the inspector when ready! Date Rea
dY:
I ce�ify that I am the �1 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Jab Addres��VOet' go�poyp,ryo.� NE C�tY FRICylEY zP c�aa
var r�icv�v 55�121
Section Township Range Fre Mo. County
o`�°R�RSdNS MICHAEL J Pho�e
Power Si olie� Address O /'
]GC�L EI�+
TIOhI
- - -- -- _ . �. .., , ,..,
Authoriz ' nature ( 'tract omparnror Owner
��
:&OOOp1A-13 7/1/2000
Master License
55114
��„��y u�smnanvn) Phone
�51 �46-2�11
SOARD OF ELEC7RtCITY COPY INSTRUCTIONS ON BACK OF YELLOW COPY