P - 77524REQUEST FOR ELECTRICAL INSPECTION p�
1�� V�- 9 2 7 1� Minnesota Board of Electricity ;r
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
' (651)642-0800TfY/MRS1-800-627-3529 �ru�r.electricilt'.s7ate.mn.us
Describe��sing the back of the white copy if n �(µ the v�orlc,coueted,by�i� ���u�,st; _•.
�LtL_ �C`�t 'L'+'( H ( ,.i ;?�.� i I...i i
GENERAL
to 400 Ar
)1 to 800
wve 800
ITS 1 FEE
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
C�RCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus la� $.50
to 12 Units @$50 Per Unit
ach Additionai Unit @ $25
OTHER ADDITIONAL FEES
ghting Retrofit @ $25 per Fixture
enter�Pivot Irti4ation Boom (� �40
Outdoor Liqhtinq Standard
Supplemental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns I Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
�ncludes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ection Tri s $20
Investigative Fee
Reinspection Fee $20
TOTAL FEE � r.l, 5 ��
(minimum total fee is $20)
THIS AR`cA FOR INSPEC'OR USE ONLv
I hereby certiry that I inspected the electrical installation described herein on the dates stated:
PDUGtiiN ne.c
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Special Inspection @ $.31 per Mile
7HtS lN$TALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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17879271
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Y1f� �� Rou h-in Ins ection Re uired? ❑Yes
r r� , 9 p q :�] No �', Inspection Other Than Rough-In: �Ready Now ❑ Will Call
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I You must call the inspector when ready! '�. Date Ready:
I certify that I am the �1 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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- Job SRe SUeet Address - - - . . . _ . . . . _ - . .. . . . . _ .. ---1 City F• �� r �-• � � c . r -• ,-
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OwnerJOccu ant Name I
, P � Please Provide Two 2 Phone Numbers Includin Area Code i,
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�� Eleetricf�al UtiNty f� �'��Electrical Utility Address
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�, Conhactor I C[o�mpany Namre � Conlractor License Number i Master Electrician or Power Limited Technician '�.
�, i"I�ili c.i_E_�.,�il.t�� l'�.�F.t'��'.�i�.�.t?h? (��y (}f.}}�Uj ��.,LicenseNumber �i
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M�a�Lng Address Contrector Com an or Owner Performin Ins[ailation i
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Authorized $i nalure (Contractor or Owner Performing Ins[allation) Please Provide Two (2) Phone Numbers Including Area Code
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INSTRUCTIONS ON BACK OF YELLOW COPY BOARD OF ELECTRIGTY COPV EB-00001A-15 8.7. 2004