P - 77604REQUEST FOR ELECTRICAL IN E I `��Fy�
1 �22�340 � y �� �� �� ��
� Minnesota Board of Electricit � � s �
1821 University Avenue Suite S-128, Saint 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 necessary - the work covered by this reque�`t:
��h � e � U �d G }� C>r�-(� (Y�dn �
GENERAL FEES Outdoor Lightin Standard $1
SERVICES / POWER SUPPLIES Traffic Signal Standard $5
to 400 Ampere $25 � C� � Supplemental Fee $20
401 to 800 Am ere $50 Transformers u to 10 KVA $10
Above 800 Amoere (�a $75 Transformers over 10 KVA na $ 20
Above 200 Am ere a$10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus (�D $.50
3 to 12 Units @$50 Per UnR
Each Additional Unit @ $25
OTHER ADDITIO
Liqhtinq Retrofit an. $.25 per Fixture
Special Inspection a$30 per Hour
Special Inspection �$.31 er Mile
THIS INSTALLATION MAY I
IIII II III II lii li iii II III II III II III II III n� I�
18223404
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling UnR @$80
Additional Ins ection Tri s $20
investigative Fee
� Reinsoection Fee Co� $20
TOTALFEE
total fee is $20) et 5-
I insoected Me electrical installation desaibed herein on the dates stated:
`_---- � ,� �-�s -1
IF NOT COMPLETED WITHIN 12 MONTHS
�-�_ � �
Date: � Rough-in Inspection Required? ❑ Yes �No Inspection Other Than Rough-In: �Ready Now � Will Cali
�� J �� 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
�5���`yA�S � ��'cle � � E ���y � ��
� ��� e
Township Section Range Fire No. County
���
Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Co`de
P�°n ����1'�n �/� �� I )-(�1/C3)��r J
EI rical UGlity ElecUical UUlity Address
�1'CEL 1s�� r��sT�vv T �-•
Contrador / Company Name ConVactor Lic�nse Number Master Electrician or Power Limited Technician
� `C.� �eC„ ��c s.n c- CAD t��3 LicenseNyV�e� _� a�50 �
i�r�rr
Mailing Address (Contrador, C
y98 �,
0
�
�
any or Owner Performing Installation)
� �5��! � - E •
or Owner Perfortning Installation) Please Provide Two (2) Phone Numbers
�� �v��- y13 - �o9C� >
r rnov wneon nc c� ccrwicirv cnov -