P - 79689REQUEST FOR ELECTRICAL INSPECTION
, t-19 8� O O V ��� e' a51) 642V08 0 ATfY/ RS ti 01627 352gPaul, Minnesota 55104 "
www.electricity.state.mn.us '� '
IdentiTy the work covered by this request: � �� ����i�� i�
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR
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0 to 400 Ampere �
401 to 800 Ampere
Above 800 Ampere
;UITS / FEEDERS
0 to 200 Amoere �
JICATION, REMOTE CI
IITS OF LESS THAN 5�
Device or Apparatus �
ditional Unit � $25
OTHER ADDITIONAL
Retro�t � $25 per Fixture
�ivot Irrigation Boom � $40
tured Home Park Lots � $25
mal Vehicle Park Sftes � $5
SIGNALING
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
Transformer / Power Su for Si ns I Outline Li htin �$5
ONE & TWO FAMILY DWELLINGS, EACH UNI7
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellin Unit �$8(
Additional Inspection Trips � $20
Investiaative Fee
N�/-� J,2.. G —a-1
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I herebvi cer6fv that 1 inspected the electrical
total fee is
� � Special Inspection �$.31 per Mile '—�` `� �` � � � s A— 7"' �--j-
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY
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Request Date:/^ Rough-in Inspection Required7 es ❑ No Inspection Other Th Rough-In: eady Now � Wtl Caq
�`"-� �`� � You must call the inspector when-re� • �•ej �ate Ready: � o —
I certi(y that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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Section Township Range Fre No. Cou
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Power Supplier Address
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or Owner Perfomyna
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i tallation �
BOMD OF ELEC7AICITY COPY
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INS7AUCTION3 ON BACK OF YELL COPY