P - 76249REQUEST FOR ELECTRICAL INSPECTION �`�-`
2����� 4 91 �fl Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
, (651) 642-0800 TTY/MRS 1-600-627-3529 www.electricity.state.mn.us �"' "�
Describe -using the back of the whfte copy'rf nec�ssary - the work covered by this request:
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GENERAL FEES Outd�r Lighting Standard @$1
SERVICES / POVdER SUPPLIES Traffic Signal Standard @$5
L 0 to 400 Am�re C�a. $25 Sunnlemerital Fee na �20
�URS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aunaratus (�a. $.50
Lighting Retrofit @ $.25 per Fodure
CeMer PNot Irriaation Boom C�D $4f
Includes the Service andlor Power Supply up to 500 Amperes, M
Circuits and Two Insp�on Trips Each Dwelling Unft @$80
Additional Ins ection Tri s a$20
Investigative Fee
Reins ection Fee a $20
TOTALFEE
(minimum total fee is $201 ��� �
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I herabvi certiiv ihat I Uisw
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etecMcal installatlon desciibed herein nn the datas stated:
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S 'al Inspecfion @ $.31 r Mfle
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS,_ ,_
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��� Rough-in Inspectlon Required9 ❑ Yes o Inspectlon Other Than Rough-In: ❑ Ready Now t0 Call
5��� �� You must call the inspector wrhen readyl Date Ready.
I certiry that I am the�l LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and pereby request inspection of the electrical work at
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Electrical Utility
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actor,
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Please Provide Twro (2) P one Numbeis Including Area Code
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Address
comrac[or ucense Number Master Electricien or Powar Limited Tedmidan
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or Owner PerFarming Installation)
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Iwner Perfartnmg Installa on) Please Provide Two (2) Phorre Numbers I�luding Area Code
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PY BOARD OF ELECTRICffY COPV EB-00001M15 8.7. 2004