P - 77523REQUEST FOR ELECTRICAL INSPECTION �'�
2 � Q � � � � � � � Minnesota Board of Electricity �
1821 University Avenue Suite S-128, Saint Paul, Mi�nesota 55104
C� � �$ (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Des '-using the back of the white if necessary - the work covered by this request:
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GENERAL FEES Outdoor Li hting Standard $1
SERVICES I POWER SUPPLIES Traffic S' nal Standard $5
0 to 400 Ampere @$25 Su lemental Fee $20
401 to 800 Am re $50 Transformers u to 10 KVA $10
Above 800 Ampere (cD $75 Transformers over 10 KVA (�a $ 20
Above 200 Am ere $f0 �
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus $.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER AD
Lighting Retrofit @ $.25 per f
Center Pivot Irriaation Boom
Special Inspection $30 per Hour
Special Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED
i IIII II III II ill II III II III II III II III II III �� I�
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ONE 8 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 ins ion Tri s $20
Investigative Fee
Reins ion Fee $20
TOTALFEE �.
(minimum total fee is $20) D
THIS AREA FOR INSPECTOR USE ONIY
I hereby certify that I inspeded the electncal installatian described herein on the dates stated:
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NECTED IF NOT COMPLETED WITHIN 12 MONTHS __ __�
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Date: / Rough-in Inspedion Required? ❑ Yes No Inspection Other Than Rough-In: ❑ Ready Now Will Call
`' �� "-' You must call the inspector when ready! Date Ready:
I certi(y that I am the�,LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at•
Job Site SVeet Address ��y `
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Township ion Range Fire No. County
Yl�� c�
Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
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EI rical U61ky Electrical Utilitv Address
13562
Ave NE
0
Master Electrician or
License Number
�gnaw ��o or or renortnmg ms uon� Niease Nrohae Two (2) Phone Numbers Including Area Code
/ \ / \ /
INSTRUCTIONS ON BACK OF YELLO OPY ARD OF EIECTRICITY COPY EB-00001A-15 e.t 2004