P - 77759REQUEST FOR ELECTRICAL INSPECTION
1�� O�- 5 31 � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(657 ) 642-0800 T'fY/MRS 1-800-627-3529 www.e[ectricity.state.mn.us
❑ NEW �( REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy 'rf necessary - the work covered by this request:
Aa� ��.r�� I�� k�s T� f��k� �-����►w Q�,�,:�s
GENERAL FEES utdoor Li htin Standard $1
SERVICES / POWER SUPPLIES Traific Si nal Standard $5
0 to 400 Am re $25 Su lemental Fee $20
401 to 800 Ampere p$50 Transformers uo to 10 KVA (� 810
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or ratus $.50
ADDITIONS TO THE �ENERAL FEES
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighling Retrofit @ $.25 per Fixture
Center Pivot Irrigation Boom � $40
Manufactured Home Park Lols � E25
Recreational Vehicle Park Sites � S5
I IIII II III II III II III II III II III I� III II III q� I�
17085317
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dweiling Unit @$80
TOTALFEE
(minimum total fee is $20) p�� ��
THIS AREA Fqi INSPECiOR USE IXJLV
I hereby certify tl�at I inspected the elec4ical installa6on described herein on the dales stated:
2�'� �vvk-�
Kequest oate: Rough-in Inspectio� Required? ❑ Yes I�No Inspection Other Than Rough-In: ❑Ready Now Will Call
/����� V You must call the inspector when ready! Date Ready:
I certify that I am the �.LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at::
Job Site Address (Street, Box, or Route No.) Cily Zip Code
�S�Y� 7�e�ti�.�`s��� �it`���� tiF� F'r�`d ��� �.rY��
rR O D 2�^ ! �� I.t �:J to'
cd er�- T c�., �� c.
� Address (Contrada, Company or Owner
�� �J � rl �l r [ l e �f �✓l
a
(�i�smi- ti�s�� )
onvactor ucense numoer nnaster t�ecmGan a Power umltetl Technician
� ^ � � � � � ucense t�umber
/"�
ya s RC �.s ��u ss-3 � y
� Phone (s) Cn / � - �2 .1 / - YJ Q ��%
c� �- y a s- - a s a 3
ON BACK OF YELLOW COPV BOARD OF ELECTRICRY CAPV EB-OOOOtA-10 8.1. 2002