P - 78714REQUEST FOR ELECTRICAL INSPECTION
� 3 4 7 3 � 8 �� � Minnesota Board of Electricity -
� � m� a 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TfY/MRS 1-800-627-3529
www.electricity.stat n.us
Identity the work covered by this request: -�
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR �, D � � " �
r_�tiFani FFFS Outdoor Liqhting Standard �$7
0 to 400 Ai
401 to 800
?00 Ampere � $10
IMMUNICATION, REMOTE CONTROL,
CIRCUITS OF LESS THAN 50 VOLTS
ystem Device or Apparatus � $.50
ADDITIONS TO THE GENERAL F
12 Units � $50 Per Unit
Additional Unit � $25
OTHER ADDITIOP
ina Retrofit � $25 per F6RUre
er Pivot Irrigation Boom � $4L
�factured Home Park Lots � 9
eational Vehicle Park Sites �
Transfortners over 10 KVA � $20
Transformer I Power Supply for Signs / Outline Lighting �$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Ins ection Tri Each Dwelli Unft �$8L
Additanal Inspection Trips � $20
Investiaative Fee
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I herebvi certifv t�a1 I
�ial Inspectio� �$30 Per Hour -� "�� L] Ir 1 I••°-�-- -
oial Inspeclion �$ 31 per Mile � I (
.... .....�.. . .��.,.. ..wv e� nencocn n�Cf�A1JNFCTFI'11F
(minimum total fee is $20) p�
pecled ihe electrical installa6on described herein an Ihe dates
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T C�MPLETED WITHIN 18 ON7
I certiTy that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY �OWNER and hereby request inspection of the electrical wortc at:
Job Address (Street, Box or Roule NoJ �� � r ��Y � r I j/ Q Z�! �/ ��
5��1 t�l.; �oore 0 J T
Section Township �o Rang� Fire No. County
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Occupant Phone
Jo,�� w. Gus�u-�'so� ��.� - 5 ��- zo�
Power Sup lier Addre � O��
Electrical Contractor / Company Name '� Contractor License Number Master License Number
i.�
MailinA Address (Conj�aFtor, Company or Owner Performing Installation)
�ature Contractor, Co ny or Ow er Perfortning Installation) Phone
{� �, 7G3- 57�- 2D75�
����� � BOARD OF ELECTHICRY COFY MISTRUCTIONS ON BACK OF YELLOMI COFY