P - 77152REQUEST FOR ELECTRICAL INSPECTION '�
I�� V��� 3 01 � Minnesota Board of Electricity �. :
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 ����
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy if necessary - the work covered by this request:
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� SERVICES / POWER SUPPLIES
0 to 400 Amcere an $25
ALARM, COMMUNICATION, REMOTE CANTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A paratus $.50
ADDITIONS TO THE GENERAL FEES
Additional Unit
Center Pivot Irtigation Boom @
Manufactured Home Park Lots I
Recreationai Vehicle Park Sites
Traffic Signal Standard
Supplemental Fee @ $
Transformers up to 10
Transformers over 10 F
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investigative Fee
Reinsoection Fee a(� $20
TOTAL FEE � ' ��
total fee is $20)
I herebvi certi(v that I insoected the elecVical installafion desaibed herein on the dates stated: I
L- 2`�— �S I
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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uace: Rough-in Inspection Req�ired? ❑Yes
No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call
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� J\ You must call the inspedor when ready! Date Ready:
I certify that I m the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical wo�C at
Job Site SVeet Address /J City /
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Address (Contractor, Company or Owner Perfortning
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¢ed Sianature (Contractor or Owner PeAortnina Insl
Please Provide Txro (2) Phone Numbers Including Aree
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License Number Master Electridan or Power Limited Technician
� � l-� License Number
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