P - 76566REQUEST FOR ELECTRICAL INSPECTION �
1����- 9 0 5 3❑ Minnesota Board of Electricity r-
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 necessa the work covered by this re uest:
�XC�i_ EhlERGY �AI+�F:•� �w�rr��
GENERAL FEES Outdoor Lighting Standard $1
SUPPLIES Traffc Signal Standard C�a $5
0 to 400 Ai
401 to 800
Above 800
;UITS I FEE
0 to 200 Am ere $5 K/
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
Transformer I Power Supply for Siqns I Outline Liqhtin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiqative Fee
TOTAL FEE I �n.»���f�
(minimum total fee is $20)
OTHER ADDITIONAL FEES
Lighti�g ReYrofit @$.25 p2f Fixtu�e I hereby certify that I inspected the electrical installation descnbed herein on the dates stated:
Center Pivot Irri ation Boom @$40 Rou�" �" onre
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites $5 v�va� �NSPecT�oN oare
Se arate Bondin Ins ction $20 ���—�—�------> ;2 c�. GL�
S cial Inspection $30 pe� Hou� exPieeo neneooNe� oATE
Special Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
I I�II II �� II I� (I M� II III II I� II II) (I III I� III I IIII � �- l_^,
1 7 8� 9 0 3 3 �l�'�l' l. �'' l---> f%
Rough-in Inspection Required? ❑ Yes J[] No � Inspection Other Than Rough-In: [�Ready Now O Will Call
�/L� r�� ; You must call the inspector when ready! . Date Ready:
I certify that I am the Lx] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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iJobRi reetAddress �- � - �City��y��� f ��
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Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
�E! UGE F'1=t•�I�IY J i;� � � � �
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i Electrical Utility �� ,�Electrical Utility Address
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Contractor / Company Name ���`�� �T� Contractor License Number �Master Electrician or Power Limited Technicia
. �"'��.��iT �LECT�iIt� �1 I(Jiri � ��; (j��$3$,j IILicenseNumber
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Mailing Address (Contractor, Company or Owner Performing Installation)
4a4C1 1"i�F;�:T7[I�TAi_ �C��1�iq SATiti?' �'firUL, I�lhl 5i��.�.�?
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Authorizad Si nature (Contractor or Owner Performing Installation) �- -� �i Please Provide�Two (2) Phone Numbers Including Area Code
I �ar�� ,(b5� 6�6-�911 i )
IN6TRUCTIONS ON BACK OF YELLOW COPY ROARn nF R FCTRICIrv CnPV � .. .......... . � _. __