P - 77506REQUEST FOR ELECTRICAL INSPECTION �
1�� V 1- 9 0 5 7 Minnesota Board of Electricity �e``_ '
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriclly.state.mn.us
Describe -using the back uf the white copy if ne the �I�Gq1�[E by thi$(Qqup� t; _, ;;,,. __ .
,. �1�i�� �r_°..�"�.._�'..' h`,`k:��� �f,i�It�'` :7 ._��,_ : !, r
0 to 400
to t
FEES
SUPPLIES
)MMUNICATION, REMOTE CONTROL,
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Apparatus @ $.50
ADDITIONS TO THE GENERAL F
Unit @ $25
OTHER ADDITIONAL FEES
@ $.25 per Fixture
iation Boom (�a $40
Traffic Signal Standard @ $5
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 and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
ative Fee
ction Fee $20
TOTAL FEE �?;s,,, L-;[j
(minimum total fee is $20)
THIS AREA FOR INSPECTOft USE ONLV
that I inspected ihe electrical installation descnbed herein on the dates stated�
r�te BorMi Ins tion $20 2-Z —0 7
ciat Inspection $30 p0f HOU� ExciaEO aeAUCONEO o��
S ial Ins ectbn @$.31 per Mile
TH�S iNSTALl.AT10N MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
IIII IIIII II Ili IIIII IIIII Ilill II III IIIII II I� I II�I
1 7 B 7 9 0 5 7
���. , �
� -b��;�
� Lq1� ! Rou h-in Ins ection Re uired? ❑Yes p g [�Read Now
, _ � I 9 p q � No i Ins ection Other Than Rou h-In: y ❑ Will Call
' �::`!:`.L!{1''t
`_, ___ __ . I You must call the inspector when ready! j Date Ready:
I cettify that I am the L] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
_ _ _— — —__ _
' Job Sde Sireet Address ,
Cityi=};''T ij {� it''., ���
��:'t.� t!r.. a.ih�I.i ryc. r,�, i._._f ��ih� .�_-
L -- --- _�
I Township - � - � �Section - �� Range �ire No. — I County
i .� I� ��� I �!ii��`iy
�------- ------- �-- -...__.. L - -. _.. _ ___ I I
� OwnedOccupant Name 1�
I �r•iid S=�'L' � ._ �,m��^
!�� €! �
Utility
Please Provide Two (2) Phone Numbers'�
\ / \ /
- -- -- r- •- �� �����a��� ��,ei e rvuuwei � mascer ciec[ncian orr
�� �^i I ���_� ?�"� i[. i..�j�`i"�I�}�,.I�i i'. L';`i �' i_ ha f; ij jr'i. ; ' License Number
� Meihnp Address�Contractor -Com�any or Owner Performin� Installahon) � � � I�� ��
� �..,?!lt� . �._�.�:._ � ��..�.F,L �'.�_�! �.)q tf _,�'�, .'"3!�.; ���.. ?_i _i.�
` _ __ —_ . __ —. _ _— . . —. —. —. —_ ... _ _ _.. _—
nsd S' nature (Contractor or Owner Performing Installation) � Please Provide Two (2) Phone Numbers
I � �.\\\ � �5] q ; \
�i �� .. �i. E .L1 LJ � : _ ? .i. i � /
_—�_..—.._ _.. _ .__. .—_
�
_.._ _—_ __ __—._ —
__N)STRUCTIOt15 0N BACK OF YELLOW COPV BOARD OF EL F(;TRI�ITV l'nPV
Limited