P - 75867REQUEST FOR ELECTRICAL INSPECTION
1������ 4 2 � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TlY/MRS 1-800-627-3529 www.electricity.state.mn.us
[�scribe - g the b ck of the w' e co y'rf necessary - the work covered by thi�requ�st:
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GEN RAL FEES OutdoO� Liqhtirttl Stan @$1
407 to 800 Ampere @ $50
Above 800 Ampere @ $75
:URS/FEEDERS
0 to 200 Ampere @ $5
Above 200 Am�re @$10
�M, COMMUNICATION, REMOTE CONTROL,
:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL F
TIFAMILY DWELLINGS (PER UNI'�
3 to 12 Units @$50 Per Unit
Each Addi�onal Unft @ $25
OTHER ADDITIONAL FEES
LlaMina Retrofit id $25 rrer Fature
rection @ $.31 perMUe �
.� � eTION MAY BE ORDERED
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T1811SIOIIIIBIS OYBI' lU KVA al � LU
Transformer I Power Su I� for Si ns / OuUine Li�F Min (a�. $5
ONE & TWO FAMILY DWELLINGS, EACH UNR
Includes the Service and/or Power Supply up to 500 Amperes, Au °
Cira�is and Two Ir�spection Trips Each DweIG� Unit @$80 ��
(minimum total fee is $20) � �+c
nus aaEa wa wsrECron usE aar
I herebvi certl(v thffi I inspeded fhe electriral trretaVetlon d�
IF
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In on the dat� smted:
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�r°dt �`p'G
12 MONTHS
FOR OFFICE USE ONLY
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I��� � �ough-in Inspectlon Requ(red?�� ❑ No I Inspectlon Other Than Rwgh-In: � Ready Now �Will CaA I
�' �� V� You must ca11 the inspector when readyl DaOe Ready.
I cerbfy that I am the UCENSED CONTRACTOR ❑ COMPANY ❑ OUVNER and he�by request inspection of the electrical work at
Job Site Street Addresa City
��d.� �. i�n Cc c� S�-- V� E �-r i ,..�,
Townshlp �(1 S�lion Range � Flre No. County
OR
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l�Sl (? et�
MasOer Electridan or P
Ucer�se Ntunber
any or cmner r mung �namnanon�
� � i�c.c.1 14 �w � �. ��0 3
or Owner PerFortning InstaDatlon) Please Provide Two (2) Phone Numbeis Includirtg Area Cod�
( �g� `71 U ( 6j��65.57;
I MW RnARt) nF FI FCTRICT' COPY EB-Q0001A-15 8.'