P - 76582'7p REQUEST FOR ELECTRICAL INSPECTION �`
1� 1 O�- 9 2 4❑4 Minnesota Board of Electricity r-
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �. ,
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy if ne,ce�s$��'the wqrk,cqvere,d.by��{�4u�st; �,�� z� L�i
i T, ri�tr r'kaT kt'
GENERAL FEES Outdoor Lighting Standard @$1
SERVICES I POWER SUPPLIES Traffic Sianal Standard fo� S5
0 to 400 Ampere @ $25
401 to 800 Am re $50
Above 800 Am ere $75
CIRCUITS I FEEDERS
0 to 200 Am re $5
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
L' hting Retrofit �.25 per Fixture
Center Pivot Irrigation Boom @ $40
Manufactured Home Park Lots (� $25
Supplemental Fee
Transformers up tc
Transformers over
ONE 8 TWO FAMILY DWELLWGS, 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
Reinspection Fee (t� $20
I hereby certify ihat I
5 iel InSpeCtiOn $30 pBf Hou� exPiReo nenNOONec
Special Inspection @ $.31 per Mile
�THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF N
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I I�I II I� N i� II �I II IN II �I II III I I I� I I Hl l llll
TOTAL FEE ��j��j(j
total fee is $20)
the electrical installation described herein on the dates sta�ed:
v
WITHIN 12 MONTHS
178�9244 ��'C�'�'� �'C'/��-��
�� °"� I Rough-in Inspection Required? ❑ Yes �] No I Inspection Other Than Rough-In: [�Ready Now ❑Will Call
�'I �'!�� �a� ��I 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:
Job Site Street Address City ������ � � f�
I �ag�o ���t�a��a» F��ss ►� I
'. � ��'�»��iP ! Section li Range ��; Fire No: �� County
-P _ _. __ ..._—_.—___- �_ -----IPleaseProvideTl.._— �i��Kt�
�--- . ..—__—. _ . i. -- —
Owner/Occu ant Name wo (2) Phone Numbers Including
� ��L.��w � �Lr�jr�� ( ) ( )
I tiec[ncai uunry I Electrical Utility Address
' kCEL Ei�IEF'GY
� ---- -- . -�----- — __ T
�, Contractor / Company Name ' Contractor License Number TMaster Electrician or P
I I-ilJhl3 ��FCTFi:LC �.:t�{"i�'flFitaTlllh! �� ��gg3 �LicenseNumber
� - - _ - - - - _ _ _ —
, Mailing Address (Contractor, Company or�Owner Performing Installation) - -- �
� �,:r4i7 TERfiTTOi;IRI� �i��tD, SAThi7 F'AUL, hlhl 55'114
_— . _ _— -- _ _ _ _ -
rAuthorizod Signature (Conhactor or Owner Performing Installation) � I Please Provide Two (2) Phone Numbers I
I �oaac �� -- - - _ _ (� 5 i� � � b-: 5 t i ( )
INSTRUCTIONS ON BACK OF YELLOW COPY BOARD OF ELECTRIGTV COPY
Technician I
FR-fl(1M'IA-15 R � �nnd