P - 77716REQUEST FOR ELECTRICAL INSPECTION R�
1� 14 �� 0 J �; Minnesota Board of Electricity �- ��
❑ 1821 Universit y Avenue Suite S-128, Saint Paul, Minnesota 55104 .. . `
�� �� `'s (651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us �" `�
Describe -using the back of the white copy if necessary - the work covered by this request:
O� C- Gz� �1- '��1'1$�5
GENERAL FEES Outdoor Li htin Standard $t
SERVICES I POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere $25 - Su plemental Fee @$20
Above 200 Am ere $1U � '
ALARM, COMMUNICATION, REMOTE CONTROt
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus (� $.50
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL
Lighting Retrofit @ $.25 per Fixture
Center Pivot Imaation Boom l�D $40
Special Ins ection $30 per Hour
Special Ins ection $.31 er Mile
THIS INSTALLATION MAY I
IIII IIII� II lil II III IIIII IIIII II III II il �� I�
18143099
'QNE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unii @$80
Additional Inspection Trips @ $20
Investiqative Fee
total fee is
I hereby certi(y that I inspected the electrical installation described herein on the dates stated: I
�C'"(�- �'� I
DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
a o os -� o�s� c�
°1 Rough-in Inspedion Required? ❑Yes �JJo Inspection Other Than Rough-In: ❑ Ready Now�Will Call
`"� i 3' �� You must call the inspector when ready! Date Ready:
I certify that I am the ,�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address j ��y
lp��V �,Cerr..i L-,0..►'lL 'v� F-ri ��Gv
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Contractor
Two (2)
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Master ElecVician or Power Limited
License Number
Please Provide Two (2) Phone Numbers
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