P - 80077REQUEST FOR ELECTRICAL INSPECTION
1 �_� � ��� Minnesota Board of Electricity
� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
- (651) 642-0800 TTY/MRS 1-800-627-3529
www. electri ci ty. state. mn. us
Identity the work covered by this request: � � � j�� y�
� [r= ^r° C.
❑NEW �REMODEL ❑ADDITION ❑REPAIR f"��} � � ^: - � �"� � � "— ���,�
0 to 400 Ampere � $25
401 to S00 Am ere �$5fl
Above 800 Am ere (� $75
CIRCUITS / FEEDERS
0 to 200 Am ere C� $5
Above 200 Am re � $10
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus � 5.50
Lighting Retrofit � $.25 per Fi�Rure
Center Pivot Irrigation Boom � $4t
Manufactured Home Park Lots � $
Recreational Vehicle Park Sites �
Separate Bonding Inspection � $2f
Soecial Insoection � $30 oer Hour
Outdoor Li htin Standard (� $7
Traffic Si nal Standard � $5
Su lemental Fee � $20
Transformers u to 10 KVA �$10
Transfortners over 10 KVA � $20
Transtormer / Power Su I for Si ns / Outline Li hG (� $5
ONE & TWO FAMfLY DWELLINGS, EAGH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellin Unit �$80
Additional Insoection Trios � $20
Fee
I herebvi certifv that I insoected the electrical
FOR OFFICE USE ONLY
I IIIIII II{I� 11111 lil{I Illl� {II11 D{I� I�II{ NII {II{ �,
�f 1 1 E+ D c 8 3 6�E ��
Request Date: Fough-in Inspection Required? ❑ Yes ❑ No Inspection Other Than Rough-In:
total fee is $20)
�✓/
c' herein on tlie dates s�ed:
,_ wre
._._. �,; d- UZ
onh
--"—'�-=� � .- c
ITHIN 18 MONTHS .
�.S�S -5a �
�� 3� � d� You must call the inspector when readyl Date Ready: I
I certify that I am the ICENSED CO COMPANY and hereby request inspection of the electrical work at:
Job Address (Street, x, or Route No.) ity Zip Code
7 S ��"` iu ,�f'c.� ��»�-- �Na���1 �Ll
Phone
7�
Electrical ! y Name Contractor Ucense Number
S c � Q .5-
Mailing Address (C Mra , Company or Owner Perto ing Installation)
3/ /�L°o �/'e S. STT Lo �/�S
Authori Signature _. ny or Owner Perfortning Instellati n) Phone
BOARD OF ELECTRICITY COPY
Master L�cense Number
/I10.SDc�
,di(�rrl �J��ya�
_ 3� �- 4'O'�Q
INSTHUC710NS ON BACK OF YELLOW COPY