P - 77424�y REQUEST FOR ELECTRICAL I PE TION �
1� 8 6 G� 8 8 5 � Minnesota Board of Electricity � ���� �-; ':
1821 University Avenue Suite S-128, Saint Paul, innesota 55104 ��`
�,
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of thewhite copy if - thework covered by r�uest:
°�"`�/ �G' �G..C, -�1.��i��:/ vi� 1
GENERAL FEES Outdoor Li htin Standard $1
SERVICES / POWER SUPPLIES Traffic Signal Standard � Q5
0 to 400 Ampere @ $25
401 to 800 Am ere $50
Above 800 Am ere $75
CIRCUITS / FEEDERS
0 to 200 Am re $5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF IESS THAN 50 VOLTS
Each S stem Device or Apparatus $.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Addftional Unit lcD $25
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites $5
Se arate Bondin Ins ion $20
Special Inspection $30 per Hour
S ial Ins tion $.31 per Mile
THIS INSTALLATION MAY BE ORDERED
IIIIIIIIIiIiII11111111Elllllllllllllllll��l�
1862885�
Suaalemental Fee C� $
� Transformer I Power Supply for Signs I Outline Lightin $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 Ins ection Tri s $20
Investi ative Fee
Reins ection Fee a $20
TOTAL FEE g� ,�
(minimum total fee is $20) �V � ''
rtify that I inspected the electrical installa6an described herein on ihe dates staled:
DATE
iar �- l� �(
• � 'vU
�+ oare
IF NOT COMPLETED WITHIN 12 MONTHS
�; �....
Rough-in Inspedion Required? ❑Yes ��'I�lo Inspection OtherThan Rough-In:
q ��-�� " �
/ You must call tne inspector when ready! Date Ready: �� ��
I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request insp
Jab Site SVeet Address City
S7� �a�1l7"4/1/ 5 � �% �/�//
Township Section Range Fire No. County
'_"__ �--- .__. — /�'J%i'!ri
d Namey „
� _"- _ _
Contractor / Company Name ,
`��'T ��:�z`%�2�C.4,
Mailing Address (Contract , Company or Ov
� f� vn�� U��s;
Authorized Signature (Contrador or Owner
�
INSTRUCTIONS ON BAC F YELLOW COPY
Address
�ady Now ❑Will Call
/
%
of the electrical work at
Phone Numbers I
`l/ �I�)
c;ontractor License Number Master Electrician or Power Limited Technician
] �/� // � License I�qr,��'J'" ( �
/ CJ'T -(' � / "l
Installation)
�� �'� � r��� �s�.��
dlation) Please rovide Two (2) Phone Numbers Including Area Code
(� ��r��13 �'�) 57� -1 z�c�
BOARD OF EIECTRICITY COPY pa_nnmm�_�s a��nne