P - 76555REQUEST FOR ELECTRICAL INSPECTION
1� 1��- 910 3� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 x�r�r.electricitv.slate.mn.us
sing the back of the white copy if necessa the work covered by this re uest:
EXC�L i�hiE�r:ur 5A{J�R'S SuJ:CTt,i�
GENERAL FEES Outdoor Lighting Standard @$t
/ POWER SUPPLIES Traffic Siqnal Standard (cil $5
/
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
Retrofit
I Home Park Lots i
Vehicle Park Sites
Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
Transformer I Power Supply for Siqns I Outline Liqhting @$5
ONE & 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 Insoection Trios (� $20
Fee
=n.
� �� ::
���_`
e,; :
TOTAL FEE j Q�4,�
total fee is $201
that I inspected the electrical installation described herein on the dates stated: �
%�,.----� �Z_ 10 ' � � I
Special Inspection @ 5.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
I IIII II III II lil II I� N I II II III II I II II NI II I II I(III
1 7 8 1 9 1 � 3
���-��-� - �-��,_� .�
°"� i Rough-in Inspection Required? ❑ Yes �] No �'��. Inspection Other Than Rough-In: [�Ready Now � Will Call
'���� f��j� � You must call the inspector when ready! '�. Date Ready:
I certify that I am the `Lx1 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
--- - - - ----- - T
�ob ste sc�ee� aad�e�_ ____ _ � cty F R I S3 f._ E Y�; hl
�.��� �-r_ c�!��;���ra�.�� �p� H��r �::; �}
_ I � IY.��Sry'-.l l 1.�5
rOwner/Occupant Name
; RC�F1S z7Ui_:Li� �
Fire No.
l ) i �'i h10 K (�
.. L— . -..- - - �— — - Please Provide Ti._.. __ — -
wo (2) Phone Numbers Including
� � �
i �tsk L_ � haE::F;CiY �
_ -- -_- -- — —
� CoNractor / Company Name '� Contrac[or License Numbe�Master Electrician or F
HLrhf ( EI..ECT�'iIC G�7hF'OFiATID'i�! ('�^ � t� " LicenseNumber
...H �i�u�J
_ i i_ ___ _... ___ .._.._
Ineai�;��dre� �(��tr��ao�t,o�(� j�panyo�r`O�wr�ne�rperforminglnstallation) �
�t�iI�IT F'i`tt;L q (�hi � 5114
_ ---_ _ _ __ _ _ _
Authorized Signature (Contractor or Owner Performing Installation) Please Prowde Two (2) Phone Numbers
'7t,at� �� (6 � �.) �, � � _� � �. ! ( )
IN$TRUCTIONS ON BACK OF VELLOW COPY BOARD OF ELECTRICI7V CoPV
�
Technician I