P - 79934REQUEST FOR ELECTRICAL INSPECTION
' Minnesota Board of Electricity
� 1-396-176 � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -
(651) 642-0800 TTY/MRS 1-500-627-3529
www.electricity.state.mn. us
Identity the work covered by this request:
❑'NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR
� � Above 800 Ampere �
CIRCUITS / FEEDERS
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or aratus �$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS (PER UNI�
3 to 12 Units �$50 Per Unit
Each Additional Unft � $25
OTHER ADDITIONAL FEES
Li hUn Retrofit �$25 r Fxture
Center Pivot Irri adon Boom �$40
Manufactured Home Park Lots � $25
Recreational Vehicle Park Sites � $5
�r'-5
XCEL Eh1ER4Y SAVER'S SWITCH
Transformers u to 10 KVA �$10
Transformers over 10 KVA � $20
Transformers I Power Supply for Signs I Outline Lighting �$!
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling UnN (� $80
Additional Insoection Trips � $20
FOfl INSPECTOF USE ONLY
I hereby cerlify Mat I inspected Me
ROUGH IN
Fiwti wsvECnori
TOTAL FEE
total fee is $20)
herein on tlie detes sfeted:
OATE
, � 2 .°°� _ o,s
FOR OFFICE U8E ONLY
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Reque��2 Rough-in InspecGon Required? ❑ Yes C�No Inspection Other Than Rough-in: �Ready Now ❑ YVIN Cali
You must call the inspector when ready! Date Ready:
I certiiy that I am the li� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (,�r$�, Bo�q��Nn \�� City F��Y Zip Code �32
;rt bA i r t
Section Township Range Fire No. County A�{A
o�uR�SZEK THOMAS J r� Phone
Power Supplier �� dd
�L
Electrica� �qr2t�tQ� / �,�y�laipifl _ _ _ ��QN Contrector Lice�se �m�be3 Master License Number
Iyt1tV I Cl.t (C: C70RP0 [:A
MailingP�i�r�;, j�pVy�p�,�ppany��p�;p�rjp�yqgJ�� I tio�N 55114
t3[1[1 1 tfihil I�]HIP1L KC]PIU AIIY 1 1•�'
Authorize ' ature (�tractor, ampany or Owner Perfortning Installation) Phone
651 6�6-2g11
E&00001A-13 7/1/2000 BOARD OF ELECTRICITY COPY INSTRUCTIONS ON BACK OF YELLOW COPY