P - 81761REQUEST FOR ELECTRICAL INSPECTION
.�� O V�- 5 4 8� S121 Urnvers � A en�ue Su te�S 28, Saint Paul, Minnesota 55104
(651) 642-OS00 TTY/MRS 1-800-627-3529
www. electrici ty. state. mn. us
Identify the work covered by this request: ��'�/ K./ L�L�� �`
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❑NEW ❑REMODEL ❑ADDITION ❑REPAIR r
GENERAL FEES Outdoor Li htin Standard �$i
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am re �$25 Su lemental Fee �$20
401 to S00 Am ere �$50 Transformers u to 10 KVA �$10
Above 800 A re �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transfortner / Power Su I for Si ns / Outline Li htin �$5
0 to 200 Amcere �$5 ONE & TWO FAMILY DWELLINGS. EACH UNIT
RM, COMMUNICATION, REMOTE CONTROL,
�UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus �$.50
OTHER ADDITIONAL FEES
Ligh6ng RetroM � $25 per Fixture
Center Prvot Irrigation Boom � $40
Manutactured Home Park Lots ��l c1 +
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellin Unit �$Bf
Additional Insoection Trios � $20
Fee �
total fee is
FOF INSPECTOp IISE ONLV
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I hereby cerUN tl�at I in�ecled the elec4ical inslalla6on described herein on Ihe dates slatbd:
S �al Ins ion �$30 f HOUf `�"� �PE010t' °A� I
'al Ins ection � $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MO HS
— — --' ---• — — — — — — — FOR OFFlCE USE ONLY �/ � � � �^� �r i � /J � � �
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Request Date: Rough-in Inspection Required7 ❑ Yes ❑ No Inspection Other Than Rough-In: Ready Now ❑ Will Call �
° a� You must call the inspector when readyl Date Ready:
I certi(y that I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (SVeet, Box,g�, Route No.) Ciry n Zp Code /
c—i/�. //D _ � _ _ s� —��� // �_ _ /� .c �
Township
� Occupant
28(�
Address
EleCtrical Gontrecj6r M1Compan� Name
DEPENDABLE ELECTRIC. ING.
d (Co Cdf�or�py�r PE
Ceon Rapids, MN 55
Authorized Signature cta, Company or
No.
Phone
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BOARD OF ELECTHICRY COPY
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N187AtICTpNS ON BAqC OF VELLOW COPV