P - 75763REQUEST FOR ELECTRICAL INSPECTION
1- �"�_��� � g121 UnNe ity A en�ue 8uite S! 28, Saint Paul, Minnesota 55104 - �
(651)642-08007TY/MRS 1-800-627-3529 www.elecri-icity.state.mn.us
Describe -using the back of the white capy'rf necessa the work covered by this re uest: �o„F ��� ^
�xc"�� �r���GV sAV��°s sw�rcN r�� ���
GENERAL FEES Outdoor Lighting Standard @$1
SERVICES I POWER SUPPLIES Traffic Sianal Standard a(�. $5
8Q0 Am re$75 Transformers over 10 KVA $ 20
FEEDERS Transformer I Power Su I for SI ns / Outline Li htin $5
9 Am re $5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
200 Am re $10 Includes the Service andlor Power Supply up to 500 Amperes, All
IMMllNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUlTS OF LESS THAN.50 VOLTS Additional Ins ction Tri $20
System Device or Apparatus @$.50 Investigative Fee
ADDITIONS TO THE GENERAL FEES Reinspection Fea a(�. $20
Each Additional Unft @
TOTALFEE c
total fee is $20) �-dli�°�
FiXtu�e � � I hareby certity that I inspected the electrical installaGon d�cribed herein on the daf� stated:
�I
a$30 er Hour �`"'""""""""°"`" """
a $.31 per Mile
f10N MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS __
I I�I II I� � I� II I� II I� II i� I! II I I I� II HI I��
17813270
��j�(� f�� Rough-inlnspectionRequired? ❑Yes �]No InspectionOtherThanRough-In: [�ReadyNow�WillCall
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