P - 77123REQUEST FOR ELECTRICAL INSPECTION �
� � � �� � � � � Minnesota Board of Electricity �/Y��— f1 � �� �- � � ��
1821 University Avenue Suite S-128, Saint �au , M�°e�so 104 ;�,.
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Desc n'� usmg the back of the white copy if necessary - the work covered by this request:
+�OQCH �D��Tt��i
Above 800 Am ere a$75
CIRCUITS I FEEDERS
0 to 200 Am ere $5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus $.50
ADDITIONS TO THE GENERAL FEES
Each Additional Unit @ $25
OTHER ADDI
Lighting Retrofit @ $.25 per Fir
Center Pivot Irtigation Boom �a
Manufactured Home Park Lots
Outdoor Li htin Standard a$1
Traffic Si nal Standard $5
Su lemental Fee @ $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns I Outline Li htin $5
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 Dwelling Unit @$80
IVIALhtt I ��, �O
total fee is $20;
I inspeded ihe elecVical installation described herein on the dates stated:
DATE
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2�� /' onre
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Special Ins ion $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT
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18667576
Date: Rough-in Inspection Required? �fes ❑ No Inspectian Other Than Rough-In: ❑ Ready Now�yVill Call
� D/��Q � I
You must call the inspector when ready! Date Ready:
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I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site SVeet Address C'
3 N�S VA�N 8U R� ST N� �R IDI�rc�/
Section Range Fire No. Counry
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e Please Provide Two (2 Phone Numbers
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ElecVical UtilityAddress
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Area Code
ractor / Gompany Name GonVactor ucense number naaster tiectncaan or rower umrtea i
INC} �i.�GTi'z�C ItJC �O�'3�� �cense Number
ng Address (Contractor, Company or Owner Perfortning Installation)
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� Signa ConVactor or Ovmer Perfortning Installatlon) Please Provide Two (2) P one Numbers Including Area
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