P - 77495REQUEST FOR ELECTRICAL INSPECTION �
1� 1 V�- 9 21 4 Minnesota Board of Electricity ;'�e \�'
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �: :
' (651)642-OSOOTTY/MRS 1-800-627-3529 x�wev.electricity.state.mn.us
Descnbe -using the ba� of the white copy if ne,ce�,s�-Ethe Wqrk�ereclby� � 4e,pueSt, ���� .L �.4 ��
� ` t I- �! !. T t- h'
lICES 1 POWER SUPPLIES
0 t� 400 Ampere @ $25
401 to 800 Am ere $50
Above 800 Ampere @ $75
:UITS ! FEEDERS
0 to 200 Ampere @ $5
Above 200 Ampere @$10
iM, COMMUNICATION, REMOTE CONTROL, SIGNALING
:INTS, CIRCUITS OF LESS THAN 50 VOLTS
Each Sysiem Device or ApparaWs @$.50
ADDITIONS TO THE GENERAL FEES
TIFAMIIY DWELLINGS PER UNIT
3 to 12 Units @ 350 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Li ting Retrofit @$ 25 per Fixture
Center Pivot Imaation Boom na S40
Outdoor Liohtinq Standard
Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
Transformer / Power Supply for Signs / Outline Lighting @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Indudes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$BO
Fee
TOTAL FEE ;?�,
total fee is $201
I hereby certify that I inspected the electrical installation descnbed herein on the dates stated:
RO::GHIN DATE
2 ��. �7
�cial Inspection @ $30 per Hour __ _ � � " '°`" ""°'." . °
$�pcial Insnee tipn (� $ 31 oer Mile �
S INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTF
I llll � lll ll l� li lll ll �l ��l ll l� ll �l ll �) l llll
-,,.- :
178792L4
,
, �����- ������ �
� ���� �I Rough-in Inspection Required? ❑ Yes ?[] No li Inspection Other Than Rough-In: [�Ready Now 0 Will Call
I— a"� .� — •
?. �'`' ":. '. f`�_"' � You must call the inspector when ready! � Date Ready _
I cBrtify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
-- --- __---- ___ __--
'�, Job Site Skeel Address � City �- j j y�.'f 1�_ if iH �,j �� ry r 7• �� �
' -�n �.tr. 11'-_�.'�_ ��•'s'._:.it ; �.r; I
j � ._
'� 7ownship iI Section Range - rire rvo. I counry I
� : r:; <�a € �� �; i'F
--- p ` � I�— — --. —. _— I — -- — II — ----�--- --- — �.
j Owner/Occu ant Name , Please Provide Two (2) Phone Numbers Including Area Code �
F��.pi i! . I� / \ /
=�!_.r�tv>-..� �Jr�tV i1'J _ II
�; EfeatnGal UtiFty � TElectrical Utili[y Address `
�: I.
'.�. l: r' i.. c..'4� ��i ii �i !
I
'� Contryctor / Company Name � - Contractor License Number �Master Electrician or Power Limited Technician '�
i � � 3 .. _. .r •� . i ��� , �-,_ ' a (t � r� ---�: ! License Number
I i-; I•,��� I,'.I.�'.� iE.F.11���h! €y;ti !..,ii:3 , I
. : ! E� �.L�.I_: i !'�..G�... �
._�. __-__. ..--. -_ .-_-_-. _ �
-___'-. -- ' ___..-.
_ �_--_ ._ - . __ _ .. _ .
i Mailing Address (Contracior, Company or Owner Performing Installation)
�• -r•-. a' }� � _ 'r {'�;.!: ;:�.5, c . .0 '
I .i!!V �G.I:It t[�^. 1 l... �.�)t ��9 _t-' �.i -�-1'._�L.q ��:� _' �' —I
�� A�thorized S' ure (Contractor or Owner Performing Installation) Please Provide Two (2) Phone Numbers Inctuding Area Code �
1/ . : : .�y � 1 _ 1/ `1
7i�� \t '_� � O r� r'��-" :' � � \ /
. ._ _ I
L.
. _____ . -. _- . . _- __ .-_. .— . .-._ __ -
cruurnnuc nu ancu nc vci i nw r.ncv eOARD OF ELECTRICITY COPY EB-00001A-15 8.1. 2004