P - 76483REQUEST FOR ELECTRICAL INSPECTION "
1����- 9 0 7 3❑ Minnesota Board of Electricity "� ,o�'
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
(651) 642-0800 TTY/MRS 1-800-627-3529 x-itN.eleclricity.stale.mir.us
Descnbe -using the back of the white copy if ne_c�ssa .the ;y,qrk covered.by,(�i�s (eQ{�gst:
.' i=.�.�.�i._ i_�*��i:. J;1 .;��.it1�'_i'� �i :=��.�. � �._� i
to 400 Ampere @ $25
)1 to 800 Ampere a�$50
bove 800 Ampere @ $75
ITS (FEEDERS
to 200 Ampere @ $5 �.,c
�ove 200 Ampere @$10
1, COMMUNICATION, REMOTE CONTROL,
ITS. CIRCUITS OF LESS THAN 50 VOLTS
ach System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL F
=AM1LY DWELLINGS (PER UNIT)
!012 Units @ $50 Per Unit
�ch Additional Unit @ $25
OTHER ADDITIONAL FEES
�hting Retrofii @ $.25 per Fixture
�nfer Pivot Irripation Boom (c� $40
Traffic Signal Standard
Supplemental Fee (a� $
Transformers over 10 KVA $ 20
Transformer / Power Supply for Signs / 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
TOTALFEE I •-? . �;,
��n.: �:
(minimum total fee is $20)
that I inspected the eleclncal installation described herein on the dates stated:
DnTE
�-�-�-{--p-�-' % 3 '� 7
S -al It1Sp2CtI0n @$30 pBf HOUf exawEO;nenNOONe� �-- oATE
$ I Ins ection $.31 per Mile
iHl$ IjJSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
�-----•------------------- ------------------- ---------------------------------
IIII II II� II Ifl II III II III II lil II Iil II IH II IB I IIII
1 7 8 7 9 0?�J
, �;� � ����� ?�
' LP4tl. i Rough-in Inspection Required? ❑ Yes ?[] No I Inspection Other Than Rough-In: Q:Ready Now ❑ Will Call
��� .....�.���:`i_ipy '.
��� �� .�� You must call the inspector when ready! , Date Ready:
'--.—__---_ . —. � - �
I cert{fy that I am the f� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
-- --- - __ _ - - -- ---
JobSiteShestAddress..__- _f i_. ._�City�f��l ;��;,_i=�?� !��� �5�ir�._'i—
� ti .i. '.EE �'.�11 I�h�i��tif� ���i
� ToWnshiD �; Section ��. Range I Fire No. �, County
p .� _ .. � � � se Provide� � �:' ': _
_ _ H 1'•' ;� r: Yi
IOWnerlOccu antName � �
wo (2) Phone Numbers Including Area Code
'`
,r,�lhl_?:..�;'� il',i.�r�f:,�: -._ I� ) � )
�, tieancai unnry '� Electrical Utility Address --
.f �., i L � i`� 1=. :. I.} I� j
_ _ _- -__ _..— ,..___.
rConiractor / Company Name � II Contractor License Number Master Electrician or Power
I ��t��" 7 3�_�:.� E i .�.� I 3��1�'��.��' �'i 1'���i !,�i� ��l�i��,y License Number
�— - ---._ .__ ._.. _ . _— . ''_ ..---- �-
j AAaiNng Address (Contractor, Company or Owner Performing Installation)
::'.._,!lL+ -�F.:F:sT��._..;t_ Fii:ia'�7?9 Sr�._�I! 'r'r�I�_ r�., 5�,is.��
L��y� i Please Provide Two (2) Pqhone Ni
_
A orix9d $� n�ontractor or Owner Performing Installation) - I
�P _..---- ---�--- — � �s�! � i-i{4n rv��.i .�. i
_ �
IN9TRUCTIONS ON BACK OF YELLOW COPY aOqRn oF F� Fr.rRir.irv cnov
: Including Area
�
�A