P - 75777REQUEST FOR ELECTRICAL INSPECTION
�� 9 4 2� 6 4 6� Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Sairrt Paul, Minnesota 55104
�cp�Q (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Descrit� ' the back of the e py'rf nec�ssary - the xrork covered by this request: �j- �e.
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GEIdERAL FEES Outdoor Ughting Standard $1
SERVICES / POWER SUPPLIES Traffir. Si�mal SYan�iarti (df R5
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Apparatus @ $.50
ADDIi10NS TO THE GENERAL FEES
ILY DWELLINGS (PER UNIT)
; Units @ $50 Per Unit
uiditlonal Unit � $25
Fbdure
5 ecial Ins ecGon $30 er Hour
S Ir�s on @ $.31 �r Mile
� THIS INSTALLATION MAY BE ORDERED
IIIII IIItI �IIII II II� I�III IIIII lllll IIIII �� I�
19426469
Transformers u to 10 KVA $10
Transformers aver 10 KVA $ ZO
Transformer / Power Su I for SI r�s / Outlhre Li $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includ� the Servke andlor Power Suppiy up to 500 Amper�, M
Circuits and Two Inspection Trips Each Dwel4ng Unit @$80
Addi�onal Ins 'on Td $2Q
Investlgative Fee
Reins 'on Fee $20
TOTALFEE
(minimum total fee is $20) '°'
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I hereby certKy that I inspected the etectrical hisfaVedon desamed herein on fhe detes sta�:
I IF NOT COMPLETED WITHIN 12 MONTHS �
FOR OFFICE U8E ONLY ��/_ � �/� �'
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�' Rough-In Inspeclion Requir�i9 ❑ Yes � Inspecdon Othar Than Rough-In: ❑ Ready Naw Uv�+m Cep
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� Yau must caU the h�saactor when readyi Da6s Ready.
I certify that I am the ICENSED CONIRACTOR 0 COMPANY ❑ OWNER arM hereby requ�t insp�ion of the electrical wrork at
Job SRe Street Address t
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Ta � ( on Range Fire No. e 1�
Please Prwide T`j ji
l5 �'�3) 7��i-
Ave NE CQ�°��� ��� Master Electridan or
�5304 ( � Licenae Number
or crypr�er�rtnmg I�Iladon) Please Provide Two (2) Rhone Niunbe�s I
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