P - 78028REQUEST FOR ELECTRIC�L INSPECTION
.�- 5 3 0- 5 0 3 0� Minnesota Board of Electricity �/yQQ -
1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
(651)642-0BQOTTY/MRS 1-800-627-3529 www.electriciry.state.mn.ur
❑ NEW � 0 REMODEL ❑ AQDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
SERVICES I POWER SUPPLIES
0 to 400 Amcere Cal 825
CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIO
Lighting Retrofit � $.25 per Fixture
Center Pivot Irrigation Boom @ yt(
Manufactured Home Park Lots @ $
Recreational Vehicle Park Sites
Transfortners u to 10 KVA $10 -- '
Transformers over 10 KVA @$ 20
Transformer I Power Supply for Signs I Outline Lighfing @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
Additional Inspec6on Trips La1$20
Inves6aative Fee
TOTAL FEE .-"j /�
(minimum total fee is $20) L�U ��
iN15 AREA FIXIINSPECiqY USE CMV
I hereby cer6ry that I inspected the electrical installa6on described herein on ihe dates sfated:
Se arate Bondin Ins tion $20V ( Z-- ��
S ial Ins 'on $30 r Hour Ex�n�oi�e,raor+eo TE
S ial Ins tion a.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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15305030 � ��,�Q
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Request Date: Rough-in InspecUon Required7 ❑ Yes No Inspection Other Than Rough-In: ❑Ready Now Will Call
� I � You must call the' or en ready! Date Ready:
I certiy ihat I am the LICENSED CON NY ❑ OWNER and hereby request inspection of the electrical work at::
J Site Address (Street Box. or Route No.) CiH T.iP Code
2-1 �ek--��erraC � I 2.
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�� � Please Provide Two (2) Phone Number(s;
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or
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GOnV8Ct0� LICEnSC Nu(Ilbet MBStP.f EIBCiflGi8f1 Of Pan
CI�!r'f�'l.l' !..(/ License Number
� Installation) , I/ I
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IN57RUC710NS ON BACK OF COPV BOARD OF ELECTRICRV COPY EB-00001A-14 e.t. 2002