P - 79110'7 REQUEST FOR ELECTRICAL INSPECTION
1� 1 O 0- 412 � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
�iq`ut (651)642-0800TTY/MRS 1-800-627-3529 www.electricitystate.mn.us
`v
❑ NEW EMODEL ❑ ADDITI N❑ REPAIR Describe -using tne back of the white copy if necessary - tphe�xrork covered by this request:
�i`��1`'1 �Q J ( '- l % % ' � 0 �5
GENERAL FEES Outdoor Li htin Standard $1
SERVICES / POWER SUPPLIES Traffic Si �al Standard $5
0 to 400 Am re $25 Su lemental Fee $20
40110 800 Am re $50 Transformers u ta 10 KVA $10
Above 800 AmDere �$75 Transformers over 10 KVA C� $ 20
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
Additional Ins 6on Tri $20
Investi alive Fee
ReinspecGon Fee (� $20
LINGS PER UNIT TOTAL FEE I 5'C7
�50 Per Unit (minimum total fee is $20) p�� •�
Jnit @$25 Tws na�r, Fae uuv�cTOrs usE aar
I hereby certify that � inspected Ne electrical insfallaAOn described herein on the dales sfa0ed:
OTHER ADDITIONAL FEES
� $.25 per Fixture � �-�, `f' "' � � � � %
1 Iill II iil 11 ffl II Iif il 111 II Iil (i III il III � I� I
1 7 0 0 4 L 2 8
��� ��
� ���
�,�� -�l d
R uest Date: Rough-in Inspection Required? ❑ Yes No Inspection Other Than Rough-In: OReady ow Will Call
�V'" 1 1` �� You must call the inspector when ready! Date Ready:
I certify that I am tlie �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the eiectrical work at:
Job Sile Address (SVee4 Box, or Route No.) City Zip Code
'���-( S�i nso� q,�� tJ� �r� c� �eu SS�(3�
so r1
lake, MN 55304
�ino IC�.
� Two (2) Phone Number(s
�''78'z� )
masc� r�ecmGan or
License Number
INSTRUCTIONS ON BACK OF YELLOI�bi�Y� �`6'��'�p �F ELECTRICfTY COPY . EB-00001M14 8.1. 2002
ji +