P - 76300° �2EQU�EST FOR ELECTRICAL INSPECTION
1� 7 9 7- 5 2 5� Minnesota Board of Electricity '• ;
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
' , (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
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Describe - sing the back of the white copy ff necessary - the work covered by this request:
EX�EL EhfE�:GY S�t+�'EF:'� S�lITCH
GENERAL FEES Outdoor Liqhtinq Standard C� $1
461 tn 800 Am re $50
Above B00 Ampere @ $75
;Uli5 / F�EDERS
0 tq 200 Am re@$5
Ahove 200 Am�ae Q$10
tM, COMMUNICATION, REMOTE CANTROL, SIGNALING
1UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
iIFAMILY DWELLINGS PER UNI
3 to 12 UnRs @$50 Per Unit
Each Additlonai Unit @ $25
OTHER ADDITIONAL FEES
Lighting Retrofit (a� $.25 per Fixture
Transformers u to 10 I(VA $10
Transformers over 10 KVA @$ ZO
Transformer I Power Supply for Signs / Outline Lightlng @$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unft @$80
TOTALFEE
total fee is $20) �8� �'�'
I inspected the electrlcal Inslellatlon described frereln on the dates stated: I
ae tlortai ms on m yzu vr—+—•-1 �/ /� ��
S �21 lI1S 'On @$30 pef HOU� ����moNm unre
S ' Inspection @ $.31 r Mile
'1'HIS IAISTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
'I l �.� i;�� RECp JUN 14 200�
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�aro: Rough-in InspecUon Required? ❑ Yes �] No Inspection Other Than Rough-In: [� Ready Now � WIII Call
�! .� �. ,� Q� You must qIl the inspector when readyl Date Ready:
I cert'rfy that I am the �I LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elecVical work at
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7t,15 I�E ,.�AGItSQh� ST
Township SecUon Range Fire No. County
uwner(cu:cupent wame Please Provide Two (2) Phone Numbers I
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EleeLical Utility Electripl Utility Address
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Contractor / Cmnpany Name Contractor License Number Master Electrician or P�
HUh�I I ELECTF:IC I:.Of�:F'OFifit I lOhl �� �� fjg�� ��nse Number
AAaqfng Address (Contractor, Company or Owner PerForming Instella5on)
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Aflthof6�ed $Ignature (Contractor or Owner Performing Instellatlon) Please Provide Two (2) Phone Numbers I
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