P - 773581 7 S 1 3 3 H 7 REQUEST FOR ELECTRICAL INSPECTION
� � Minnesota Board of Electricity �(�Q�- ���j�( ( �e \ '
❑ 1 8 21 University Avenue Suite S-128, mt Paul, Minnesota 55104 _ -
� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy if ne���the ��v�e�.by t�h���t. � S� z�.��
0 to 400 A�
401 to 800
Above 800
;UITS I FEE
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units (cil $50 Per Unit
Pivot Irrigation Boom �
ictured Home Park Lots
Outdoor Lighting Standard
Tra�c Sianal Standard (a�
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / Outline Li htin $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 $20
TOTALPEE
(minimum total fee is $20) 2O -��
iHl$ AREA FOR INSPECTOR USE ONLV
I hereby certify that I inspected the electrical installation described herein on the dates stated:
�,
S cial Inspection $.31 er Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
IIIIIIIII�III�IIIIIIIII�IIIIIIIIII�I�IIIIIIII�
17813�87
,'"'� `" °`- 'i, Rough-in Inspection Required? LJ Yes 2J No I Inspection Other Than Rough-In: QReady Now ❑ Will Call
���, You must call the inspector when ready! I Date Ready:
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
���+4�e��5 1�(-�T . _ cay � . '. - —
i
Section I Range
F'FC. �: l7 I
Please Provide Two (2) Phone Numbers Including
\ / \ /
C /._ e �� '' ' �Contractor i s " j Master Electrician or P
� License Number
� --__._.. -- -�--- ---
M�Ij�A�dra�,C��!'tt11�tS1flLyf'IUWHUyerf�rr�l,�jalll"�(til��_�._�iii �r'l�i�,d�
S1U ! Ft tt� 1
_ - - — -- --
I A�rized ' �� e(Contractor or Owner Performing Installation) -� i P���Prr�i��� �It�ne Numbers I
laww ;� i ) ( )
INSTRUCTION$ ON BACK OF YELLOW COPY eOARD (]F FI F�TRI['ITV t'nPV