P - 77169REQUEST FOR ELECTRICAL INSPECTION
1�� `t dJ � 719 � Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
/ICES / POWER SUPPLIES
0 to 400 Amoere an $25
(651) 642-0800 TTY/MRS 1-800-627-3529 ww��.electriciry.state.mn.us ``'�;�" �
copy if necessary - the work covered by this re �
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�L FEES oor Li hting Standard @$t
Traffic Si nal Standard $5
Supplemental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA al� $ 20
ALARM, COMMUNICATION, REMOTE CANTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus a$.50
ADDITIONS TO THE GENERAL FEES
Each Additional Unit @
Center Pivot Irrigation Boom �
Manufactured Home Park Lots
Inciudes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ion Trips $20
Investi ative Fee
Reins ion Fee $20
TOTAL FEE
(minimum total fee is $20) S�
THIS PREN FOR INSPECTOR USE ONLV
I herebv certifv lhat I insoeded ihe elecUical installation descnbed herein on the dates staled:
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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uace: / Rough-in Inspection Required? ❑ Yes �lo Inspectlon Other Than Rough-In�Ready Now 0 Will Call
� ✓ b� You must call the inspector when ready! Date Ready:
I certify that I am the�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address �� C�ty �` ��
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Township Section ange Fire No. CounTy /'� �
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O Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
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Electrica tilit �' Electrical Utility Address ��� _���b � O�
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ConVactor I� ��eELECTRIC �ontractor License Number Master Electncian or Power Limited Technici
J - _ __ — ' �� /� n � �� License Number
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� Maiiing
MN 554N ;�, � :
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