P - 81874REQUEST FOR ELECTRICAL INSPECTION
1'( (� P� Minnesota Board of Electricity "� �� �
� 1 V O- 0 5 5 `� �a 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� ,� (651) 642-0800 TTY/MRS 1-800-627-3529
www.electricity.state.mn.us
Identity the work covered by this request: n�CG�� A � C� �`���? � /� O�- -y--� /_
i�� I"r i� ! G
❑ NEW ❑ REMODEL ❑ ADDtTION REPAIR
GENER,4L FEE Outdoor !.' htin Siandard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10
Above 800 Ampere �$75 Transformers over 10 KVA �$20
Above 200 Am ere � $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or ratus �$.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units �$50 Per Unit
Each Additional Unit � $25
Manufadured Home Park Lots �
Recreational Vehide Park Sites �
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service and(or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellin Unit �$80
AddRionalins ection Tri s � $20
Investi tive Fee
Reins ion Fee � $20
TOTAL FEE � D� S�
(minimum total fee is $20)
OR INSPECTOH USE ONLY
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herebvi certifv that I inspected the eleclrical ir�tallaHon des�xibed he2in on the detes st�d:
5 ial In ion �$30 er Hour — '"°"`�'"" / ' ��w� � I
S ecial Ins ection �$.31 per Mile �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED I T COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY
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Request Date: Rough-in Inspection Required? Yes o Inspection Other Than Rough-In: eady Now ❑ Will Call
6�J —�� You must call the inspector when readyl Date Ready: (� '�J 'O �
i certify that I am the LICENSEQ CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Adclress (Street, Box, or Route No.) City � Zip Code
S�SG 3���i s TiQa r` � �,Q�d�e�
Occupant
I,t�e n d GlJea
Power Supplier
G
/ Company Name
E e��'�r`c
ntractor, Company or Ow
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(Conhador, Company o
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Phone
7( 3-,S"'7/-�/07�
ess
Contractor License Number Master License Number
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1����Su/%e/� S �Q( r Q��e/"a��i///n.-S.5 %3�
�erf ing Installation) Phone
�'�63-��0 -.�as_
B D OF ELECTFIICITY COPV INSTRUC710NS ON BACK OF YELLOW COPY