P - 80171REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
• 1-396-162 � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-500-627-3529
www. electricity.state.mn. us
Identify the work covered by this request:
O�IEW ❑ REMODEL ❑ ADDITION ❑ REPAIR
0
� ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
3 to 12 Units �$50 Per Unit
Each Additional Unit � $25
OTHER ADDITIONAL FEES
Lighting Retrofit � $25 per Fixture
Center Pivot Irrigation Boom � $40
Manufactured Home Park Lots � $25
Recreational Vehicle Park Sites � $5
Separate Bonding Inspecdon � $20
Special Inspection � $30 per Hour
X�EL Eh1ER4Y SAVER'S SWITCH
Transformers u to 10 KVA �$1�
Transfortners overl0 KVA � $20
Transformers / Power Supply for Signs / Outline Lightinq �$:
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dweiling Unft �$80
Additional Inspection Trips � $20
FOP INSPECTOP USE ONLY
I hereby cerMy t�,
ROUGM IN
FINAL INSPECTIIXJ
�
TOTAL FEE
total fee is $20)
tlescribed herein on ihe dates a
DATE
DATE
FOR OFFlCE USE ONLY
( (�IIII IIIII IIIII III�I �I�I III� �� � � I� �y �
* 1 3961 628* _l� �'S�
Reque�$��� Rough-in Inspection Required? ❑ Yes G�No Inspection Other Than Rough-in: � Ready Now ❑ wll Call
You must call the inspector when ready! Date Ready:
I certity that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address�78�t, soX, o�� o.�E DR W °� ��p�+ � rP coda ��
Section Township Range Fire No. County awarca
Occupant PFwne
Miu�a Pn-rRiein e .� � .,
Power Supplier Address
�L �Y
Eleetrical Contrector / y Name Contractor License Number Master License Number
HUf+(T' ELE�IG CORPORATION CA 00883
Mailing Add�ress contractTORl�iLy�� ; sninri�PAVi;'°MN �1 � a
Authorized, .S,ignature (Contractor, Company or Owner Pertortning Installation) Phone
r�Me16 ,�OMA�iN�i 864 �-29�'I i
EB-00001A-13 7/1/2000 BOARD OF ELECTRICITY COPY INSTRUCTIONS ON BACK OF YELLOW COPY