P - 77215o REQUEST FOR ELECTRICAL INSPECTION ��°�
� � ° (� � � � 4 5 $ � Minnesota Board of Electricity �-. �
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1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 ��
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state. mn. us
Describe -using the back of the white copy'rf necessary - the work covered by this request:
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GENERAL FEE Outdoor Lighti S ndard @$1
SERVICES I POWER SUPPLIES _ .,. _ Traffic Si nal Standard $5
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus lo? $.50
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighting Retrofit @ $.25 per Fi�ure
Center Pivot Irriaation Boom lc� S40
Supplemental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns / Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Addftional ins ion Tri s $20
Investi ative Fee
Reinspection Fee $20
TOTALFEE
(minimum total fee is $20) � '
THIS AREA fOR INSPECTOR USE ONLY
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I hereb ce i that I ins eded the electrical insta ation d ibed herein on the dates stated:
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Speciallnspection $30 erHour exa�eo�nenr�ooNen— pp� I
S iai Ins ion 5.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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L8404582 �oOJ �7_` �
vate: Rou h-in Ins
g pection Required? ❑ Yes No Inspedion Other Than Rough-In: ❑ Ready Now Will Call
You must call the inspector when ready! Date Ready:
I certify that I am the�l LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Sfte SVeet Address City
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Township Section Ranae Fire No. CounN .
ConVactor/COmpafi Nam�v
5.��72 �7�dsort �
Mailing Address (Contractor, Company or
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Authorized Sig (Contra Owi
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INSTR TIONS ON BACK YELLOW COPY
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Electrical Utility Address �J
i 57 ��t� ,,c� f�/t '�t a �f /7/ .s's"�o,3
Contractor License Number Master lectrician or Power Limited Technician
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forming Installation)
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iing Installation) Please Provide Two (2) Phone Numbers Including Area Code
-� (T63�,73�? -6,; G Z� )
BOAR�OFELECTRICITV(:c)PVi cesrnn�e_�c o. �rvi.