P - 77105�. REQUEST FOR ELECTRICAL INSPECTION �����
1� J 1 O- 0 5 5� Minnesota Board of Electricity ' - s� s
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 � _�
(651)642-OSOOTTY/MRS1-800-627-3529 www.electricity.state.mn.us �,��
Describe -using the back of the hite copy if necessary - the work covered by this r uest: �,�
�To �`n ��dn o �ce �citU�c$ �1�5 /
GENERAL FE Outdoor Lighting Standard $t
SERVICES / POWER SUPPLIES Traffic Sipnal Standard (a? $5
Above 800 Am ere $75
CIRCUITS / FEEDERS
0 to 200 Am ere $5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus a(� $.50
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIO�
Liphtinp Retroft a(�. $.25 per Fixture
Fee @ $20
uptolOKVA@$10
over 10 KVA a(� $ 20
Includes 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
Investi ative Fee
Reins ion Fee $20
TOTALFEE
(minimum total fee is $20)
THISAREAFORINSPECTORIISEONLY �
(�O� V
I hereby certiy that I inspected the electrical installation described herein on the dates stated:
-l�-� I
Special inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rough-in Inspection Required? ❑Yes �lo Inspection OtherThan Rough-In:
!� �� 0^ �� You must call the inspector when ready! Date Ready:
I certify that I am the � ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request:
Job Site Street Address ,
�5.2 / 1�e9/S 1�� ° ,Qle
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/ Company Name
Now � Will Call
of the electrical work at
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Please Provide Two (2) Phone Numbers
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Electrical Utility Address
Contractor License Number Master Electrician or P
1 ` , /1 License Number
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:ompany or Owner Performing Installation)
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ador wner ormi I Ilati lease Provi e Two (2) Phone Numbers
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