P - 78251� REQUEST FOR ELECTRICAL INSPECTION
'� �/� ,� C� � Q 3 8 � Minnesota Board of Electricity -
'•t d v 1g21 University Avenue Suite 5-128, Saint Paul, MinnesoTa 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
❑ NEW ❑ REMODEL ❑ ADDITIO EPAIR Describe -using the back M ihe white copy'rf necessary - the work covered by this requesL
5�3
GENERAL FEES Outdoor Li htin Standard S1
SERVICES I POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Am re E25 �C"i Su lemental Fee $20
401 to 800 Ampere p S50 Transformers u to 10 KVA $10
IALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
�r Each Svstem Device or Apparatus @$.50
12 Units � $50 Per Unit
i Additional Unit @ $25
OTHER AD
6ng Retrofit � 5.25 per f
1er Pivot Irtiaation Boom
Hour
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14658389
Tr�sfortners over 10 KVA $ 20
Transformer I Power Su I for Si ns I Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes lhe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
(minimum total fee is $20) � 30 .:
TMIS AREA FOR INSPECiIXi USE ONLY
I hereby cer6y ihat I inspected the electrical insWlation described herein on the dafes sfated:
�APLETED WITHIN 12 MON'
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Requ� Date: Raugh-in inspection Required7 ❑ Yes �NO Inspedion Other Than Rough-In: ❑Ready Now [�Wfll Call
" f "�O - Q� You must call the inspeUor when ready! Date Ready:
I cerUfy that I am the C�}LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby �equest inspection of the electricxl work at:
Jab Site Address iStreel Box. a Route �b.) City Zip Code
61 Tal�'adge Way NE FRIDLc.�'Y 55432
(6�� 750-9296 ( )
��er r��an or
License Number
Mmiag naaress (t:onuaCror. c:anpany or Owner PHrforming hsfalation)
4401 - 85th Ave N, Brooklyn Park, ML�T 55443
' -� 1763-315-3205 I
BACK OF YELLOW COpY BOqRp OF ELECTRICITV COPV EB.00OO1M74 8_1. 200?