P - 758121 REQUEST FOR ELECTRICAL INSPECTION ''
1�� �� 5 3 6� Minnesota Board of Electricity
1821 Universiiy Avenue Suite S-128, Saint Paul, Minrresota 55104
(651)642-0800TTY/MRS 1-800-627-3529 www.electricity.stale.mn.us y""''� ��
Describe -using the back of the whfte copy'rf rrecessary - the work covered by this request:
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GENERAL FEES Outdoor Lighting Standard @$1
SERVICES / POWER SUPPLIES Trdflic Signal Standard @$5
i 0 to 400 Amoere (o� $25 c� ���ia��rai F� r� a�n �
CIRCURS OF LESS THAN 50 VOLTS
ystem Device or Apparatus @ $.50
ADDITIONS TO THE GENERAL FEES
UnR
Unit
�er Hour
rpe M7e
MAY BE
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18205369
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / Outline Li htln $5
ONE � TWO FAMILY DWELLINGS, EACH UNIT
Inciudes the Service and/or Power Supply up W 500 Amperes, All
Circuits and Two Inspection Tdps Each Dwelling Unit @$80
Addi�onal Ins 'on Tri $20
Irnestigative Fe�
Reins 'on Fee $20
TOTAL FEE ,r�� p�Q
(minimum total fee is $20) "'l'lJ
iW4AREAFOR W�ECfOR USE OM.Y
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I hereby cettlfy tlmt 1 ir�d the elediical 6�talf llon d�esa@ed herein on 5�e det� stefed:
IF NOT COMPLETED WITHIN 12
FOR 0>F:CE +�"s= 0"vLY
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�'�ry /� Rough-in Ins�c;tlon Required9 �Yes ❑ No Inspectlon Other Than Rough-In: � Ready Now�WBi Call
`` ��� You must call the ins
pedor when readyl Date Reedy.
I certify that I am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby requast inspectinn of the electrical work at
Job Site Street Add
City
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T�h�P Sectlon Range Fire No. County
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OwnedOccupent Name Please Provide Two (2) Phorre Numbers Including Area Code
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Electrical Uh1'dY Electricel Utlti[y Ad
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Contrador / Company N � nUador License Number Master Electrictan or Power LIm�Ted Techn(di
ti
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Meiling Address (Contractor, Company or Owner Pertortning InstallaGon)
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Authorized Sigr�dire (Co tra r or Ow� PerFormi�nstallaUon) Please Provide Two (2) Pho�re Numbers Including Area Code
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IN3TRUCTIONS ON BA OF YELLOW COPY BOARD OF ELECTRICIT' COPY ce rmnn. n. e e, e�