P - 76967REQUE�T FORELECTRICAL INSPECTION � ;
.L � O� o- 4 4 3 Minnesota Board ot�flectricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) �42-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the badFof the white copy'rf necessary - the work cove�ed by this reqYest:
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GENERAL FEES Outdoor L' hti Standard $t
, SERVICES / POWER SUPPLIES Tra(fic ' nal Standard S5
0 to 400 S25 Su mental Fee $20
401 to 800 Am $50 Transformers u to 10 KVA $10
Above 800 $75 Transfomiers over 70 KVA $ 20
CIRCUITS / FEEDERS Transformer / Power Su for S' ns / Outline Li htin $5
0 to 200 Am $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am $10 Includes the Service andlor Power Suppty up to 500 Ampetes, All
ALARM. COMMUNICATION. REMOTE CONTROL. SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit � a80
CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units �i! $50 Per Unit
LATION MAY BE ORDERED �
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Fee @ $20
TOTAI
iimum total fee is
I inspeded Ihe �I installa6on desaibed
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NNECTED IF NOT COMPLETED WITHIN 12
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, �a�� Rough-in Inspedion Required? Yes ❑ No Inspection OtFier Than Rough-In: ❑ Ready Now � WiN Call
��' �� You must call the inspector when ready! Oate Ready:
I certiiy that I am the 0 LICENSED CONTRACTOR ❑ COMPANY OWNER and hereby request inspection of the electrical work at
Job Site Street Address City
7 I. �n �+ . N F �r�ci ic
Tormship Sectlon Range Fire No. CouMy
Owner/OccupaM Name Please Provide Two (2) Phone Numbers Indudi�g Ar� Code
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, Company or Owner
License Number Master Electrician or Power Limited l
License Number
Please Provide Two (2) P.hone Numbers Induding Area
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ELECTRICAI� INSPfCTIp�i�S PERM�r Na
C�RECTIO�i'. aR�' .f� ..,ryr �:�::,' a�►Te
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OMmad'Occupant J�
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Property Address lY ? v� .L—y �^" �jitl""- ' Zfp
The following items are deviatlons from the accepted stendards of const►ucdon at the above desc�fbecl
premises. Numbers after each item are appficaWe Natlonal ElecMcal Code Sectlons:
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O �tp�cMr br ninsp�atlon bsion cowring wlrfn�.
wlll b� mad� at tims of nsxt fn�on.
Sipf and rotum this iorm to Msp�ctor wh�n cornctions haw bwn mads but no latsr
tl�n (D�e)
� Robert Clauson
1586 E. Se�ctan# Ave.
Maplewood, MN 55109
Stg�ature of Insfaller
-777-7885 for Aeinspectlon - 7:00 - 8:30 e.m. �� '
Monday - Friday except holidays.
RC-01