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P - 78721REQUEST FOR ELECTRICAL INSPECTION 1-:3 5 4- 3 5 7 �` g Minnesota Board of Electriciry 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us , Identify the work covered by this request: �� ❑NEW ❑REMODEL ❑ADDITION ❑REPAIR GENERAL FEES SERVICES / POWER SUPPLIES 0 to 400 Am re �$25 401 to 800 Am re�$50 Above 800 Am re � $75 CIRCUITS / FEEDERS 0 to 200 Amcere � $5 ALARM, COMMUNICATION, REMOTE CONTROL, SiGNALING CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Each S stem Device or aratus (� $.50 ADDITIONS TO THE GENERAL FEES MULTIFAMILY DWELLINGS PER UN 3 to 12 Units �$50 Per Unit Each Additbnal U�it � S25 Lighting Retrofit � $25 per Fixture CeMer Pivot Irriaatlon Boom � S4( � � Outdoor Li htin Standard � $1 Traffic Si nal Standard � $5 Su demeMal Fee � $20 Transfortners u to 10 KVA �$10 Transformers over 10 KVA � $20 Transformer / Power Su for Si ns / Oudine Li hti �$5 ONE & TWO FAMILY DWELLINGS, EACH UNR Ir�ludes the Service andlor Power Supply up to 500 Amperes, All Circuits and Two Inspection Trips Each Dwellin Unit �$8f Additional Inspection Trips � $20 Investiqative Fee total fee is $20) b(U � I herebv cer1iN Mat I inspected the electrical installalion described herein on S THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPIETED WITHIN 18 MQNTHS FOR OFFICE USE ONLY i��r�i� ��i �� i� r�� ir� i�� 7� �E 1 3 5 4 3 5 7 4* �� rs0 Request.Dat� �� Rough-in Inspection Required? ❑ Yes No Inspection Olher Than Raugh-In: Ready Now 0 Will Call '� You must call the inspector when readyl Date Ready: I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work aY Job Address Street, Box,g Route No.) C Zip Code � 3�q %a v%ar � =:�r,�l�, �.��3Z __.._.. �..,.� ..r O�o � - ,.� ,.�. � ,,, �r� a �'� Cu o w� �Y �" �O ,�. -e.5 P7�3,78 3-� l 7 4 Power Supplier Address � � ,^ . � � X C� -e � /Sl � G�`1 �5 r� �;; �„�J s N Electrical C trac[or / Company Name Conhactor License Number Master License ber �ivi� �� 'l�G d d � 0,.� � Mailing Address (Contractor, Company or Owner Performing Installation) /� �3 a./ �� n G � .S7`' N�' � S ��S 7 Authorized Signature (Co r, pany or er Perfortning Installation) Phone ,,Z� � � 3 E&00001A-13 7/1/Z000 BOARD OF ELECTHICtTV COPY INSTAUC710NS ON BACK OF YELi.OW COPV