P - 76474REQUEST FOR ELECTRICAL INSPECTION "
1-787-895 0 y � _:���
❑ Minnesota Board of Electricit �v-r
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 wiric.eleciricity.slale.mn.us
pescnbe -using the back of the white copy if necessary - the work corered by �hi re �e�st:.
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� GENERAL FEES Outdoor Lighting Standard @$t
SERVICES I POWER SUPPLIES Traffic Sianal Standard (� $5
$25 Supplemental Fee @ $20
a'� $50 Transformers u to 10 KVA $10
$75 Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns I Outline Li htin $5
$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
$10 includes the Service andlor Power Supply up to 500 Amperes, All
ON, REMOTE CONTROL. SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
� CIRCUITS. CfRCUITS OF LESS THAN 50 VOLTS
to 12 Units @$50 Per Unit
ADDITIONAL FEES
Home Park Lots �
'ehide Park Sites
Reinspection Fee $20
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TAL FEE ;'•�, ..,,_,
(minimum total fee is $20)
THIS ARER GOR INSPECTOR USE ONLV
I hereby certify that I inspected the electrical installation described herein on the dates stated:
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TMIS t�t$TALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12
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I�e: II Rough-in Inspection Required? ❑Yes 7[�No � Inspection OtherThan Rough-In: [�Ready Now OWill Call
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� �You must call the inspector when ready! �ate Ready:
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I certi(y that I am the �] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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'. Job Sit@ Street Address �ity 1- �'. � i.� I,_ h�j� �'�^?v �t �� r' '�
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I Owner/Occupant Name �
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' Range i Fire No. I County
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'�, Please Provide Two (2) Phone Numbers
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i ElecVicel Utilfty � Electrical Utility Address �
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Conhactor / Company�Ni-ame � ��- ontractor License Number Master Electrician or Power Limited Technician
I i.i�.�F`T E:.i (-{..,lit:�C. �.[Ij�!'1'i1i-'�^.�i'1s.�1R; C _y t'�i7ij:-�,j LicenseNUmber
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i Mailinp Address (Contractor, Company or Owne5+r Performing Installation) _
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iAutizori�ed Si ature (Con[ractor or Owner Performing Installation) � i Please Provide Two (2) Phone Numbers Including Area Code
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