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P - 75683��o��o � D�aibe -usim,� the back of the white copy ff r�ec Sr'�''� GENERALFEES REQUEST FOR ELECTRICAL INSPECTION Minnesota Board of Electricity 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 (651) 642-08007TY/MRS 1-800-627-3529 www.elecdricity.state.mn.zrs �- the work cover� by this requ -� �l Gg3 � �P[t.�c-i T 1 � �.f/i,� Atmve 800 Am ere �c $75 � CIRCUITS / FEEDERS 0 to 200 Am re $5 Above 200 Am re $10 ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS 3 to 12 Units @$50 Per Unit � Each Additional Unit @ $25 OTHER ADDRIONAL FEES Li hting Retrofit @$25 er FoQure Cerder Pivot Ir� ation Baom @$40 Manuhactured Home Park Lots $25 Recreatinnal Vehide Park Sit� @ $5 Se te Bondin Ins ecbon $20 Speaal Ins�tion @ $30 er Hour S ' Ir�s 'on @ $.31 r Mile S INSTALLATION MAY BE ORDERED [ I I�I II III II �II � I�I II III II III II I� II III �� I� 2D7!71�1❑� Traffic Sianal Standard ONE 8 TWO FAMILY DWELLINGS, EACH UNIT Includas the Service andlor Power Supply up to 500 Amperes, A� Circuits and Two Inspection Trips Each Dwelling Unit @$80 Additional Ins 'on Tri $20 Investl ative F� Reins 'on P� $20 TOTdLFEE (minimum total fee is $20) ,S . � tws a�a Foa u�cr� usE aar I hereby certify ttiat I inspected 9re electrical I�tsVadon desamed herein on fhe dates sta�: rs�w /°� �f '�{r23-Yi'J / � rw�uu�cnor, �_' ��. — � ^ J� �- � �OR OFFICE USE ONLY I�CD AUG - 7 2001 � D6 � 01 �� Rough-in Inspecdon R�uired9 ❑ Yes �Ido InspecUon Other Than Rough-In: ❑ Ready Now �ARl�all ��. �� You must call the inspedor when readyl Date Ready: I certify that I am the,�LICENSED CONTRACTOR ❑ COMPAIVY ❑ OWNER and hereby request ins�Ction of the electrical work at Job S�ie Street Address City ! / S �,¢-� � �( Township Sectlan Range�~ Fire No. CouMy �� Owner/ nt Name Please Provide T (2) Phone Niunbe�s Irtdudi� Area Code �c. \ � \ � Electricel Util4y Electrical Utllity Address If .�-- /v � � r. Company or Owner Perfortning Ins1a0 � a�?? Z e riUactar or Owner Pertormi� Insfellado� U A' � Master Eledridan or P Licer� Number �'3`� Z 6 le Two (2) Phorte Numbe�s � L �� \ �