P - 77383REQUEST FOR ELECTRI L INSPECTION
1� 7 8 1� 3 O 8 � Minnesota Board of Electricit �I� ��
1821 University Avenue Suite S-128, S in Faul, Mi��sota 55104
(651) 642-0800 TTYIMRS 1-800-627-3529 x�irx.electricih�.state.mn.us
-using the back of the white copy if necessary - the work covered by this request:
EXCEL EhlERGY SAVER'S SWTTCH
GENERAL FEES Outdoor Liqhtinq Standard na $1
401 to 800
Above 800
ALARM, GOMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or ApparaWs @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
>fit @ $.25 per Fixture
Irrigation Boom @ $4C
I Home Park Lots @ $
Vehicle Park Sites la�'
5 ecial Inspection $.31 per Mile
THl3 IIJ$TALLATION MAY BE ORDERI
IIII II I� I I IN II I� II III II III I I NI II I� II I� I IIII
17813080
Supplemental Fee $20
Transformers u to 10 KVA �$10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns I Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
,.n
`� ��1�- -
„-.
ction Fee $20
TOTALPEE
(minimum total fee is $20) ZO -� O`��
iH15 AREA FOR INSPECiOR USE ONLV
that I inspected the electrical installation descnbed herein on the dates stated:
:���z —f`�- z �-a1
3CONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
�� ���LL��� C ! Rough-in Inspection Required? ❑Yes �] No �'i Inspection Other Than Rough-In: [�Ready Now ❑Will Call
� �, You must call the inspector when ready! ''�, Date Ready:
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electriral work at:
y�t/�,� _ _ _ ____ - --- ----- --- --
J��#�tQ1�e tt�Ui'1�_ Ft� Cit
i yFFIDLEY
�: Township � �Section Range � � Fire No.
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. __. . _ - � - -- -----__. - _. r---_. _ _.
,°��°��`�'i�`T'�IAhII:Y Ahll�l (leasej
Two (2) Phone Numbers
' \ /
�� Electrical Utility � - j Electrical Utility Address
': XCE� ENE�uY
�
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; ����� �Rz4�eAla�i�4C L���,Q��-rI �� Contractor lj��se,Nwqb�-.il Master Electrician or Power Limited Technician
, t �� � h y l, t1 V Zf J , License Number
,___.._ .._ . . __.. ._ . __..__. . .._._. _ . .I...
,, Mailing Address (Contractor, Company or Owner Performing Installation)
' L�04 TEf,f;ITQF�IAL �[IAD, Sr�INT F'AUL, h1N 5511�
_ ._ _ —
Authorize�i Si nature (Gontractor or Owner Performing Installa[ion) ��.�Ig��Proyicje Twq,�� ihpne � mbers Including Area Code
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INST TIOl15 ON BACN OF VELLOW COPY BOARD OF ELECTRICITY COPY
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R EB-OOOOtA-15 8.1.2004