P - 79928REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
� 1-396-183 � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
(651) 642-0800 TTY/MRS 1-800-627-3529
www. e%ctricity. sta te, mn, us
Identify the work covered by this request:
�I�EW ❑ REMODEL ❑ ADDITION ❑ REPAIR
o co aoo
401 to 8
�
0 to 200 Am ere �$5
Above 200 Am ere (� $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGP
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Ap ratus �$.50
ADDITIONS TO THE GENERA� FEES
MULTIFAMILY DWELLINGS (PER UNI
3 to 12 Units �$50 Per Unit
Each Additional Unit � S25
XCEL ENEROY SAVER'S SWIT�H
Transformers u to 10 KVA �$10
Transfortners over 10 KVA � $20
� Transformers / Power Supply for Signs / Outline Lighting �
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 5�0 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$E
Additional Inspection Trips � $20
FOq INSPECTOR USE ONLY
ROUGHIN
FfNAL INSPECTION
�TAL FEE
fee is $201
DA7E
DATE
FOR OFFICE USE ONLY
I�IIIII IIIII (I�I IIIlI IIIII ��� ��� � 1�
* 1 3961 834* ��� �a'sD
Reque Rough-in Inspectlon Required? ❑ Yes �No Inspection O[her Than Fiough-in: Q�Ready Now ❑ Witl Cafl
You must call the inspector when ready! Date Reatly:
I ceAiiy that I am the [� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job AddreS��t, so���R �E ciy �� z�P coaa �32
Sectlon Township Range Fire No. County /I�(1(�(A
r ,.;
�°�`�1L1�RINl3 C JAMES . Phooe
Power Su_ oolier �Y Address
]GCxL
Electrical (',qpf�ctpr,/��J�.r'� ConVactor Lic�;e Zlyry�� Master license Number
tiUlY 1 Cl.t W�1(){7tlC
Mailin9 911tlrioSS �c,.('.amQ� 1G.pL�, P,@r(onrypp.lo��°�� �114
L3�lti Ui1PIL Ft�.7PU.1 Sp�IIY 1-t'
Authoriz ' nature (C�ptracto mpan or Owner Perfortning Installation) Phone
� 651 6�8-Z911
EB-00001A-13 7/1/2000 BOARD OF ELECTRICIN COPY INSTRUCTIONS ON BACK OF YELLOW COPY