P - 76486REQUEST FOR ELECTRICAL INSPECTION
1����- 8 9 6� Minnesota Board of Electricity ;
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �: �,
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Oescribe -using the back of;he white copy if necP.�s_a�-�the Wqr��.pvered.by��S rgqu�,st; ` r� ,. -- .�: ,
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GENERALFEES
SUPPLIES
0 to 400
)MMi1NICATION, REMOTE CONTROL,
CIRCU�TS OF LESS THAN 50 VOLTS
�vslem Device or Apparatus na $.50
Z Units � $50 Per Unit
Additional Unit @ $25
OTHER ADDITIONAL FEES
ng Retrofit (a� $.25 per Fixture
Traffc Signal Standard
Supplemental Fee @ �
Transformers uo to 10
� Transformer / Power Supply for Signs I Outline Lighting @$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
Additional Inspection Trips @ $20
Investigative Fee
Reinsoection Fee (cil $20
TOTAL FEE E?(�;,
nimum total fee is $20)
I hereby certify that I inspected the elecirical installation descnbed herein on fhe dates stated:
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SpBCtuil klSpediOn @$30 pe� HoU� exPiREO; �enNOOr�eo onre
S Ins ection $.31 per Mile
THIS tNSTALI.ATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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17878968
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`xi`G� ,I Rough-in Inspection Required? ❑ Yes
„� ._ L.: Ft _ �] No �' Inspection Other Than Rough-In: [�Ready Now �Will Call
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___ I You must call the inspector when ready! �I Date Ready:
I certify that I am the Ll LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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Job-Sde Street Address CitY!- i �- Y L ''- �� ��",`�
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�, OwnerlOccupant Name '� Please Provide Two (2) Phone Numbers Including Area Code
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'� Elec�ric-al Utili� - �, Electrical Utility Address
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i �onuacwr i �wnpany name p ��� Contractor License Number I Master Electrician or P
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Me+6ng Address (Contractor Company or Owner Performmy Installation)
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A��Cred S' turc (Contractor or Owner Performing Installation) � Please Provide Two (2) Phone Numbers
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Limited
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