P - 76056REQUE3T���'�-„�h�CTRICAL NSP CTI �j /-
�� 3 4 7��F J� � 1ne21 UQ n'�nrtersity A enu Suite S-128, Saf�� in�esota�� [o
� (651) 642-OB00 T1Y/MRS 1-800-627-3529 -
w�vw.electricity.state.mn.us � � �
laentliy me xrork covered by this requast
0 NEW ❑ REMODEL �DDPTION ❑ REPAIR
ruwtn surruts TraHic S StarMard C� $5 '
I Am re�$'25 lemerdel Fee �$20
�0 Am re�$50 Transfotmers to 10 KVA �$10
�00 Am re C� $75 Translormers over 10 KVA �$'10
�� Traru4former / Pomrer S for Si / OutQne Li �$5
I re�$5 ONE & TWO FAMILY DWEWNGS, EACH UNR
�� re�$10 Includ�s the Service and/w Power SuPPh �P to 500 Ampere,a� All
MMUNICATION, REMOTE CONTFlOL, SIGNAUNG Cira�s artd Two I�pe.ctlon Trbs Each Dwel6rm Unit ��eo �'
IITS OF LESS THAN 50 VOLTS
Device or APParahrs � $.50
DDI170NS TO THE GENERAL FEES
UNts �$50 Per Unit a5` � (minimum total fee is $20) O
Id�on81 Unit �$'15 wn w�mn usE a�nx y
OTHER ADDITIONAL FEES � Ut.c:c,. %�,� �'t �O � �/�'°`f�...
Retrofit � $25 r FocMe ��., 83 � �oZ- — , R
'hrot I ation Boom � $40 ' 1�' � �
Nred Home Park Lats @.�5 I hereby certlfg tl�at I i�pec6ed the aiectricai ����;
onal Vehide Park Sit�s �$5 '�" �' �� nnh
i Boridi Ir�s 'on (� $20 ' �
on �$90 r Hour 'TM"� � � o� L�
on �$.31 r M�e ' 2 f�QEa
� TIi151NSTALLATION IMAY BE ORDERED DISCONNECTED IF T COMPLETED iMTHIN'Fd�MONTHS
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FOR OFFlCE USE ONLY 6�-
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R Date: Rough-(n Inspectlon ReqWred? �es ❑ No Inspectlon Other Than Rough-In: ❑ Ready Now 0 V{Im Ceq
I� J You must call the fnspecmr when ready! Oate Ready:
I cert(fy that I am the ❑ UCENSED CONTRACTOR ❑ COMPANY �OWNER and hereby �u� inspection of the elecUlcai work at
Job Address (Street. Bm4 or Route No.) CHY Zlp Code
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EH-0OOU1A-13 � 7/1�20� . BOApD OF ELECTpICRY COpY INSTRUCi1pNS ON BACK OF YEILOW COPY
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