P - 78171REQUEST FOR ELECTRICAL INSPECTION
1� 5 7 3���� � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
1) 642-0800 TTY/MRS 7-800�27-3529 www.electriciry.state.mn.us
�Y.
❑ NEW ❑ REMODEL ❑ ADDITION EPAIR D/e's+cribe -using the back of the white copy if n�/'/ - the work covered by this request:
� � � r I c.ijV/..✓ V !� � /' ��%'r4•-� � c�-I�✓
GENERAL FEES Outdoor Li h6n Standard $1
SERVICES I POWER SUPPLIES Traffic Sianal Standard Cd 55
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A ratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit (� $25
OTHER ADDITIONAL FEES
� Rehofit @ $.25 per Fixture
Pivot Irri ation Boom $40
ctured Home Park Lols $25
6onal Vehicle Park Sites fa� SS
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up l0 500 Amperes, AII
Circuits and Two Inspection Trips Each Dwelling Unit @$80
TOTAL FEE I ^ _ �i� I
(minimum total fee is $20) ��� �������
THIS AREA FOq MbPECiOR USE ONtV
I hereby certify that I inspected the electrical installation described herein on the dates staled:
JMPLETED WITHIN
^l.:t/�C`��
Iliil lllll lllll lllil l�lil lllll lllli �l�ll p� l� ,� ---� ��; �
15737752
o�G��� O1 �S� �`'� �'
Request Date: Rough-in Inspection Required? ❑ Yes 8'I'b Inspection Other Than Rough-In: ❑Ready Now Call
8��, f�� You must call the inspecla when ready! Date Ready:
I certify that I am the �ZJ'` CIC€NSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Address (Street, Box, or Rout Ciry Zip Code
� �-y�T�- -�- - � � �'s Y 3 Z
� C/ /1
INSiRUCTONB ON
�.�1 U� � � 1�3)��z Y32�(m�
Power Suppli� Address
���a� �� �. ���ua mas�eroecmcaanorraxerumrtearechnician
¢C . � / � / � License Number
l
ry or Owner peAormfng Installation)
•r o / L �✓✓ (� ! G r �Gldt,/
rnpan stallatlon) Phone (s)
�s� Yz c �
BOARD OF ELECTRICITV COPY E tA-14 8.1. 2002