P - 75984REQUEST FOR ELECTRICAL INSPECTION ���. ,
1��� 0� 4� 5� Minnesota Board of Electricity �f3c��"— 03 O�S
„� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
(651) 642-0800 TTY/MRS 1-800-627-352 www.electricity.state.mn.us
Des�cri6e -using the back of the white copy'rf nec�ssary L- the work covered by this request:
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GENERAL FEES 0 oor Lightin Standard @$1
SE CES / POWER SUPPLIES Traft'tc Sigmal Standard $5
0 to 400 Am�ere a(� $25 Suonlemental Fee [�D �20 / ._
:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL F
TIFAMILY DWELLINC�S (PER UNllj
3 to 12 Units @$50 Per Unft
Each Additional unit @ $25
OTHER ADDffIOPIAL FEES
LigMing Retrafit @ $.25 {�r Focture
Center Pivot Irriaation Baom f�D $40
5 Ins 'an @ $.31 r Mile
THIS INSTALLATION MAY BE ORDERED
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18204958
" Rough-In Insp�tlon R�utredT �Yes
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I cerMy that I am the � LICENSED CONTRACTOR ❑ COMPANY
Job Slte Street Addrass
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Townsh�P � Sectlon Ran
ma�ung naaress �contractor, comyaqy or
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INSTRUCTIONS OId BACK OF YELLOri COPY
Transformers to 10 KVA $10 �
Transformers wer 10 KVA @$ 20
Transfortner / Power Supply for Signs / Outline Lighting @$5
ONE & TWO FAMILY DWEWNGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, An
Cirarits arM Taro I�p�tion Trips Each DweAmg Unit @$80
Addi�omal Insp�tion Trips @ $20
Investlqative Fee
total fee is
I frereby certlty U�at I inspeded ihe electrical inataVatlon descn'6ed herein on fhe dates ste0ed:
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!CTED IF NOT COMPLETED WITHIN 12 MONTHS
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❑ No Inspactlon Other Than Rough-In: ❑ Ready Now �WiU Call
Dete Ready. `
WNER end hereby request mspection of the electrical work at
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ovide Two (2) Phorre Numbers Including Area Co
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sr Master Electridan or Power LMited TerJ
Lk:erise Number
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BOARD OF EIECTRICITV COPV FR-fl(1001A-15 a� �nne