P - 77360REQUEST FOR ELECTRIC L INSPECTION
1 �8� 330 4 ��f:..;
� � ❑ Minnesota Board of Electricity �U(,S���B�y ,�-;
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55�04
(651) 642-0800 TTY/MRS 1-800-627-3529 ww�x�.electrieity.state.mn.us
Describe -using the back of the white copy if necessar� the work covered by this re uest:
EKCcL ENEFiGY SAV�F:'S SiJITCH
GENERAL FEES Outdoor Liahtina Standard (� $1
0 to 400 Ai
401 to 800
I
ALARM, GOMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
Unit
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irrigation Boom @ $4C
Manufadured Home Park Lots @ $
Recreational Vehicle Park Sites @
Seqarate Bondinq Insoection (�a $21
Traffic Signal Standard
Supplemental Fee @ $
Transformers uo to 10 I
� Transformer / Power Supply for Signs I Outline Lighting @$5
ONE & 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
Additional Inspection Trips @ $20
Investiqative Fee
ua
TOTALFEE �
(minimum total fee is $20) 2�'sa
ihat � inspected the electrical installation described herein on the dates stated:
� � 3^�
Special Inspection $.31 per Mile
THIS INSTAILATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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1 7 81; 3 3 0 4
`[��(� �y I Rough-in Inspection Required? ❑Yes �] No �� Inspection Other Than Rough-In: [�Ready Now ❑Will Call
'� You must call the ins�ector when readvl �. Date Readv�
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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Jo �� he t � - City
'i �«� �I���Ih1 AVE NE I FRIDL.EY
Iownship ! Section Range '� Fire No. County ��a K�
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Oytpgr{Dc,CN�amg, ���� � L_ � K � � Please Provide Two (2) Phone Numbers Including Are
K H a P !t 1 � 1 /
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� Electrical Utility ��, Electrical Utility Address
XCEL EhlEE:GY
��. Contractor / Compan Name - � � Contractor License Number ! Master Electrician or Power Limited
' HUMT �LELXTFiIC CORF'ORATIpN CA 4�$8.i ',ucenseN�mbe�
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i Mailing Address (Contractor, Company or Owner Performing Installation)
L�c�a TE��zra�za�. �a�n, saz�� ��AU�, Mr� 55���
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Authorized Signature (Contractor or Owner Performing Installation) �� �I Please Provide Two (2 Phone Numbers Including Are
� II �65i� 646-2�1 i � �
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INSTRUCTIONS �N BACK OF VELLOW COPY BOARD OF ELECTRICITY COPV Fa_nnmm�_�