P - 774962-019�306
Describe -usina'ttie back of the white
SUPPLIES
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REQUEST FOR ELECTRICAL INSPECTION ��`�
Minnesota Board of Electricity �/aL'o, _�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
- the work s�overed by this request:
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<nn, I:UMMUNI(:A I IUN, KEMOTE CONTROL, SIGNALING
;UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus $.50
ADDITIONS TO THE GENER4L FEES
iIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per UnR
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Li htin Retrofrt @$25 per Fixture
Center Pivot Irrigation Boom @ $40
Manufactured Home Park Lots (� $25
Outdoor Lightin Standard $1
Traffic Si nal Standard a$5
Supplemental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns / Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
TOTAL
total fee is ;
I hereby certiy that I inspected the elecVical installation described herein on the dates stated:
ROUGHIN DAiE
FINpLINSPECT�ON : ... DATE
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special Inspection $.31 per Mile
_ THIS INSTALLATION MAY BE ORDFJ2ED DISCONMECTED IFNQT COMPLETED WITHIN 12 MONTHS
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Dat � ^ Rou h-in Ins
/ J g pection Required? ❑Yes �- nspection Other T gh-Irc ❑Will Call
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You must call the inspector when ready! Date Ready: ��
I certity that I am they�llAENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elechical work at:
Job Site ee�, C-
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E rical Utllity ElecUical Utili
Co GpmpanyName
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Mailin A r�( on ctor, o any or (�wner Performing InstaL
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Authorizad tu ( on ctof or Owner Perfortn' g Installatioi
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INSTRUCTIONS ON BA K OF YELLOW COP eOpR
riease rrowae iwo (�) N17o rs Including Area
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�o ce� um6er Master Electrician or Power Limited T
i � License Number
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Please Provide Two (2) Pho rs I�duding Area
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�ITV COPY EB-00001A-15