P - 76579REQUEST FOR ELECTRICAL INSPECTION �''�
� a 8 2�� 4, � 9 � Minnesota Board of Electricity �� �
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 °Ft
(651) 642-0800 TTYIMRS t-800-627-3529 www.electricity.slate.mn.us
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Describe -using the back of the white copy if necessary - the work covered by this request: ���.�nj �n Q �,�.t S
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GENERAL FEES Outdoor Lightin Standard @$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Amoere na $25 Sunnlrmantal Fae (nl A90
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus $.50
ADDITIONS TO THE GENERAL I
MULTIFAMILY DWELLINGS IPER UNITI
Unit @ $25
OTHER ADDITIONAL
(�a. $.25 per Fixture
Center Pivot
Special Inspection $30 per Hour
Special Inspection $.31 er Mile
THIS INSTALLATION MAY BE ORDERED
I IIII II I II � I�' �' ��� I Il II III II II I�� I�
Transformers over 10 KVA $ 20
Transformer I Power Supply for Signs I Outline Liqhting (d $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trios (� $20
TOTAL FEE I �
(minimum total fee is $20) yQ � .�
I hereby certify Nat I inspeded the electrical installation described herein on the dates stated:
ROUGH IN � pq�
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FIN4LINSPECTION ATE
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IF NOT COMPLETED WITHIN 12
18204990 �������(��
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Date: Rough-in Inspection Required? Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Cail
�� U� You must cail 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 ��
s O �• G��tl01r Ct �C-C, � C� ��. 7'r'� ��
Township Section Range Fire No. Counry �
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or Owner
Nlease Provide Two (2) Phone Numbers Including Area Code
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Electrical Utility Address
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Contractor License Number Mast r Electrician or Power Limited Technician
License Number
or uwn Nerto Ing Installation) Please Provide Two (2) Phone Numbers InGuding
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I COPY BOARD OF ELECTRICIN COPY Fa-nnnn�