P - 79990� REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
� 1-396-169 � 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:
❑�IEW ❑ REMODEL 0 ADDITION ❑ REPAIR
IALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS. CIRCUITS OF LESS THAN Sa VQLTS
� MULTIFAMILY DWELLINGS (
� 3 to 12 Units �$50 Per
Park
� $.31 per Mile
XCEL ENEROY SAVER'S SWITGH
Outdoor Li htin Standard � $1
Traffic Si nal Standard � $5
Su lemental Fee � $20
Transformers u to 10 KVA �$10
Transformers over 10 KVA � $20
Transformers / Power Su I for Si ns / Outline Li htin �
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Gircuits and Two Inspection Trips Each Dwelling Unit �$i
Additional Ins�ection Trips � $20
I herebv carfiN Mat I inspected Me
INSPECTION / �
�L FEE
is $2�l
sratea:
FOR OFFICE USE ONLY
I IIII�I �II 11II� II�II IIIII II�II I{I� �� � 1„1 �/
* 1 3961 693" �-t'��
�-Sa
Requestp3168�,2 Rough-in inspection Required? ❑Yes Q,No Inspection Other Than Rough-in: C1Ready Now ❑ Will Call
Ua/l n R
You must call the inspector when ready! Date Ready:
I certify that I am the lA LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Route No.) City Zp Code
�12 RICE C�EEK BLV NE FRIDL.E't' S5432
Section Township Range Fire No. Counry A�p
Occupant 1'� ry .- Phone
4UNDERSON PAUL 8 � i �)
Power Supplier Address
�L �Y
Electrical Contractor / Company Name Contractor License Number Master License Number
HURlT ELEGTFtIG (a4RP'ORATiOhI CA tm883
Mailing Address (Contrector, Company or Owner Pertorming Installation)
2300 TEF�t{TC�lAL f�}AD , SAINT PAUL, MM 55114 !
Authorized Si�(C�rector, C�ompanyror Owner Pertorming Installation) Phone
651 Q�-2911
EB-00001A-13 7Ml2000 BOARD OF ELECTRICITY COPY INSTRUCTIONS ON BACK OF YELLOW COPY