P - 76433REQUEST FOR ELECTRICAL INSPECTION �
1��� 1- 9 0 6 5 Minnesota Board of Electricity `� ��'
❑ `� - -
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 n�x ir.electricrfi.state.mn.us
Describe -usir� the back of the white copy if n y theW�fk, �� by,t�1iFf��St: _. f--.
� �}�.':._ i- h; � L7 t ;i Fi 5� ��. _. �}�.�.� .i I �... �'�
GENERALFEES
200 Ampere @$10
>hFMUNICATiON, REMOTE CONTROL, SIG
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Apparatus @ $.50
ADDITIONS TO THE GENERAL FEES
to 12 Units @$50 Per Unit
Irrigation Boom @
i Home Park Lots
Vehicle Park Sites
Outdoor Lighting Standard @ $1
Traffic Siqnal Standard (�a $5
Transformers u to 10 KVA $10
Transformers over 10 KVA y 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
ING Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Insoection Trios (a� $20
Fee @ $20
TOTAL FEE _ _ ,
nimum total fee is $20)
that I inspected the elecMcal installation described herein on the dates stated�
/-.�Z �°'/
5pec�al Inspection N y30 per Hour ExaiaEO aeavooNeo Dat
S ial Ins ction @$.31 per Mile
TH18 INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
I IIII II I� II I�1 II III II I� II III (I III I) III II III I IIII
1 7 8? 9 Q 6 S
� bC��' �(��-����'
I��' �I Rou h-in Ins ection Re uired?
i_ ,_} g p q ❑Yes :�] No i Inspection Other Than Rough-In: C$:Ready Now �Will Call
i a s. s t. �. :` ��i .
'�� ___ __�You must call the inspector when ready! li Date Ready:
I cer6ty that I am the I� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
— _ __ _ _ --- --
� Job Sde Street Address , z � �- -- �,. , �
�City: ; r r;t. n-.
� -�r
�.� i� �� F r�_ i i � i L � � .
�. . �.._!'. t �fi ..�._�'y._�.:.
..r ; i_ . H!`; ..
Fire No.
. _.-- — - ---- . . .. _. _- _. ---.._: _ ._ __. __ ,_.—
' OwnCr/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
� - � �,, ; ,-�,_„ � - i ( ) ( )
. i, �•ii:�:;._.t. . ,..;�:�, ,
FJBClrical UtititY � Electrical Utility Address ���
:a:�.:�:.� E.i�Eh��'t
— — - — --�--
', Corkractor / Company Name , Contractor License Number �� Master Electrician or Power Limited Technician
� 3,.�r �- r,i• - P. �.;
!��_�S'.�. !_:...�'.!��^,�.1_: ._�t�{'��`[IE1`ti�;.��i'�. �� ,,,:f} f'�ftC�r•��:r :�iLicenseNumber
� : �? C' `" �.
: ._ _ _.. __' __ ..__— __ _ _. � — .____ I�_ ...... . .... ... ..1. _ .-__ _. 1
, Mai4ng Address (Contractor, Company or Owner Performing Installation) �� �
, , s`1:.� i_�:.i"`.;? 1 [ !��C.�F•1L. ilvrii� y ,:'i�t! � { I I-'��.: ?i=•.' _ �,�.i i"; �'I
� q
.__ -_____-_ -___. _ _- ..._ ___... ...-- I
� AuthorizGd 8' nafure (Contractor or Owner Performing Installation) Please Provide Two (2) Phone Numbers Including Area Code
�� ��----I (f s? `� � ���� ; .,. r l
� � \_ � 1_� - i�'-::.. �: \ /
— -- -- - - _ I
INSTR4ICTIONS ON BACK OF YELLOW COPY BOARD OF ELECTRIGTY COPV Ee-a000�a-�5 e i �nna