P - 773821 REQUEST FOR ELECTRICAL INSPECTION ���;,\
1��� 1- 3 5 4 4 Minnesota Board of Electricity �/��S_��Qc/Q ;� �
❑ 1821 University Avenue Suite S-128, a n`{ aul, Minnes�S{ ��04 -
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.slate.mn.us
Describe -using the back of the white copy if necessary - the work covered by this request:
E?CCEL �hiEnGY SAVEfi `S Sit�ITCH
GENERAL FEES Outdoor Liahtina Standard (� $1
SUPPLIES
0 ro 400
401 to 8
Above 8
:UITS I f
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus la� $.50
to 12
dditional Unit @ $25
OTHER ADDITIONAL FEES
� Retrofit @ $.25 per Fixture
Pivot Irrigation Boom (�a $40
Recreational
Traffic Signal Standard @ $5
Supplemental Fee @ $20
Transformers uo to 10 KVA (c
� Transformer I Power Supply for Signs I Outline Li htin $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
Fee
TOTAL FEE I aO • 5���
(minimum total fee is $20)
that I inspected the electrical installation described herein on the dates stated:
Se arate Bondin Ins ction $20 % %- c
fi^--". � -
Special Inspection @$30 per Hour F"PwEO "e^�,o�N_ ' oare
Special Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS _
l IIN II I� II I� II �I II III II II{ II III Il hl II NI I IIII
17813544
�"��`� f� 5 ', Rough-in Inspection Required? ❑ Yes �.] No �',, Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
� _ 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:
��,�it��ire�l���I�ON ST hIF _ _ c�ryF6iIDLEY
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AMClKA
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O�!_Q�cNp,�t N�g ��Y �����T, I Please Provide Two (2) Phone Numbers Including Area
, 1l.i�itL Fi _ ----___ � ` � `
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� Electrical Utility '. Electrical Utility Address �-- �
XCEL EhIE�;GY '
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Con r c r/ C mpan Name Contractor License Number Master Electrician or Power Limited T
H�h�QT' EeLEGYTRiC CORF'OF'ATIOhI CA 0088,i LicenseNumber
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Mailing Address (Conhactor, Company or Owner PeAorming Installation) �-
2340 TEF�fiITOF�IAL �;OAD, �iAIhIT F'AUL., t�(hi 5'� 114
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' Authorized Signature (Conlractor or Owner Performing Installation) �-�� �- ��-� � Please Provide Twi
I � �� �i /�i :�t � �'� t5—
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INSTR�CTIONS ON BACK OF YELLOW COPV BOARD OF ELEC7RICITY COPY
Phone Numbers Including Area Coc
1i � �