P - 76580REQUEST FOR ELECTRICAL INSPECTION �
1� 7 8 1� 9 0 0 4, Minnesota Board of Electricity ,�e�`
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �: :
(651) 642-0800 TTY/MRS 1-800-6273529 wwi��.e[ectrieity.state.mn.us
Describe -using the back of the white copy if n the r by.t�i �,st;
�t�-`L ��k`�'�l SAUFK S �W�TCH
POWER SUPPLIES
0 to
FEES
� A6ove 200 Ampere @$10
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Aooaratus la� $.50
ADDITIONS TO THE GENERAL FEES '
MULTIFAMI�Y DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit •
Each Atlditional Unit @ $25
OTHER ADDITIONAL FEES
Li�hting Retroft (� $.25 per Fixture
Traffic Sipnal Standard
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 Ins ection Tri s $20
Investigaiive Fee
Reinspection Fee $20
TOTALFEE � ('j,�lj
(minimum total fee is $20)
rrus naEn FoR wsaecroa usE oN�v
I hereby certify that I inspected the electncal installation described herein on the dates stated:
Se arate 8ondin Ins ection $20 �--� - � o�
Special Inspection @$30 per Hour �sxa�ae�; ns,�r�ooNeo � oaTe
S ecial Inspection @$.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
I IIII IIIII II I� II I�I IIIII IIIII II III (I I�I II III I IIII ,' `' -,. ., % ,
178L9004 ��< ( ��'��/�,
�.. °"� 'I Rough-in Inspection Required? ❑ Yes � No I Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
��� �' �i ���� I You must call the ins ector when read !
�- —.._ _--- ----P --- Y I Date Ready:
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER antl hereby request inspection of the electrical work at:
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Job Site Street Address � 1 City � �� � �� � { ,�� -�
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55r'-
', Township � I Section Range ��i Fire No. � County
__ __ � ; n�a�:��r�
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�OwnedOccupant Name� - �� � Please Provide Two (2) Phone Numbers Including Area Code
�Ct!.?' �t�FFEFiY � � � � � �
�j Electrical Utility � -�� � Electrical Utility Address
' �CE.L �:hlEhGl`
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'�, Contractor / Company Name Contractor License Number ����. Master Electrician or Power Limited Technician
,. . r n --. 'I License Number
�-lJNT ELcC.Tr.Il� t i]F:F�Qi:AT:t01, � C�t �;jv}e�t:� �
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i Mailing Address (Contractor, Company or Owner Performing Installation)
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.�—_ _- _—_ . _.. — .._._ ._ '_ __'
; Auihorized Signature (Contractor or Owner Performing Ins[allation)� �, please Provide Two (2) Phone Numbers Including Area Code
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INSTRUCTIONS ON BACK OF YELLOW COPY BOARD OF ELECTRICITY COPY ❑a_nnnme_�s u� onn�