P - 77112REQUEST FOR ELECTRICAL INSPECTION �
� � � � O � C � � � Minnesota Board of Electricity � � ��
J � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -. �
(651) 642-0800 TTYIMRS 1-800-627-3529 wwx�.electricity.state.mn.us ��_�
Describe -using the back of the white copy if necessary - the work cover by this r uest:
Z�a�t-�� /C''T'' !-�Z
GENERAL FEES Outdoor Li htin Standard @$1
SERVICES I POWER SUPPLIES Traffic Sianal Standard (a� $5
401 to 800 Am ere $50
Hbove 800 Am ere a$75
CIRCUITS I FEEDERS
0 to 200 Am ere $5
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL
Lighting Retrofit (�a $.25 per Fixture
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
Additional Inspection Trips @ $20
Investiqative Fee
ivir�� rcc �y
total fee is $20) v� U'� �
I insoeded the electrical installation described herein on the dates staled: I
��'/�^�l �
I per Hour `""'"`�' """""""`� — �"'
1 per Mile
I MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
�i�� I� I�� II lil I� Iil �� iE� II lii II III �� �II �� ��[
18805297,
Date: � Rough-in Inspection Required? ❑ Yes � No Inspection Other Than Rough-In: �Ready Now ❑Will Call
%(����% ,i You must call the inspector when ready! Date Ready:
f
I ceRify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Street Address City
/zc� ����d������ Sf — �=r� �%��
Township �i Section Range Fire No. Count
� f� /� � � �i
Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
����1 � 1 I�kS f � ) � )
Electncal Uttld Electncal Utility Address
x C�1 I, is�r� c`� rs�f �,�f �' /' ls
�ntractor / Company Name ,, Contractor License Number Master ElecMci n or Powe imited Technician
/''� l/ �' � ` � � � v I' /r� d� � � I License Number
` C_----�- - - —�
Mailing Address (Contractor, Company or Owner Performing Installation)
,�� h� � �5 �f iti1 � , ���� , l s ��� � � .S"� / 3
��h ¢ i a r o Owner Performing Installation) / Please Provide Two (2) Phone Numbers Including Area Code
—
(� ial � yv ��/ !� ( )