P - 77505REQUEST FOR ELECTRICAL INSPECTION
1� 1 O�- 913 ❑1 Minnesota Board of Electricity ;�-
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �:
(651)642-0800TTY/MRS 1-800-627-3529 w�rii.electricitv.slale.mn.t�s
pescribe -using the back o��the white copy if ne�s�s�,r� -� he rrygrk�,oyer,ed,by.(�i,s' �e4U�st; __.,, . i. .3. __
GENERALFEES
I POWER SUPPLIES
2q0 Ampere @$10
)MMUNICATION, REMOTE CONTROL, SIG
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Apparatus @ $.50
ADDITIONS TO THE GENERAL FEES
3!0 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lightinq Retrofit (�a $.25 per Fixture
Hour
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 & 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 Inspection Trips @ $20
Investipative Fee
TOTAL FEE z;� a ��-�� y
minimum total fee is $20)
I inspected the eleclncal installafion descnbed herein on the dates stated:
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� THI$ INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12_MONTHS�
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�' "�' �� Rough-in Inspection Required? ❑ Yes :�] No I Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
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; .__�� You must call the inspector when ready! ___ 'LDa_te Ready:
I certi#y that I am the 0 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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' Job Site $Veet At-�ddress - � i�y r-,�, � ! � �^ �;; •.� ;y�;'+� c5 c, n .� .:.
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Range
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�, Owner/Occlipant Name -- `
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Please Provide Two (2) Phone Numbers I
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�trador / Company Name —� � Contractor License Number Master Electrician or P
y jf:� r rv� �� r, •r;�` ' i�4�p -� 5� u i'. -: �.-, i-: ll `75�; �=:'�° � License Number
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rtdaikng Address (Cootractor, Company or O�jwner Pertorming Installation) i
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; AW,bqrixed S' nature (Contractor or Owner Performing Installation) �. Please Provide Two (2) Phone Numbers
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INSTRUCTIONS ON BACK OF YELLOW COPV eOnRn oF Fi Fc7RiciTV cnav
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Technician I