P - 79768REQUEST FOR ELECTRICAL INSPECTION ,
Minnesota Board of Electricity 4�
1-396-536 � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529
www. electricity. sta te, mn. us
Identity the work covered by this request:
U NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR
to
IALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
THF
Each Additional Unit � $25
OTHER ADDITIONAL FEES
Lighting Retrofit � $25 per Fxture_ /� .
Center Pivot Irrigation Boom � $40
Manufactured Home Park LoGs � $25
Recreational Vehicle Park Sites � $5
Separate Bonding Inspection � $20
Special Inspection � $30 per Hour
X�EL ENER4�Y SAVER'S SWITCH
Transformers over 10 KVA � $20
Transformers / Power Supply for Signs / Outline Lighting �$E
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$SO
Additional Inspection Trips � $20
i nereuy cernty ma� i
ROUGM IN
FINRL
TOTAL FEE 11J.�
inimum total fee is $20)
Jlation described herein on Me dates stated:
DATE
��DATE �
� � �
FOR OFFICE USE ONLY
� I��I� III�� ��I �I�,IIII IIIII III�I � IIII I� ���� � V
�1 � �,
* 1 3 9 6 5 3 6 3* �
Reques� ���2 Rough-in Inspection Required? ❑ Yes I�No Inspection Other Than Rough-in: �Ready Now ❑ Will Call
You must call the inspector when ready! Date Ready:
I cer6fy that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address�Stcaat, Bo�q�.BoWaNp�..., � City �� Zip Code �21
�LO[J AIIVI IMICK
Section Township Range Fire No. County A��(a
Occu�qL, _ � J Phone
WVLr
Power Su lier �� Address
Electrical GGpt�cf{y,/�g�p�lti(V�T,'� Contractor Lic��e �ymt�L Master License Number
1"11J1Y I tl.tts 1 I'�(ISi CsA t7UGtl3
MailingA�dd�ass�c,,1'.prliQany,.pr�vae�P�qrlrympp,rp� tioa6N �,�,�
I�W Cll^ilAl_"KG7A1J bAIIVI-h' Ilw
Authoriz ' nature (�tr� ompan or Owner Performing Installation) Phone �, ��� 1
EB-0OOO1A-13 7/1/2000 BOARD OF ELECTRICITY COPY INSTRUCTIONS ON BACK OF YELLOW COPY