P - 77113REQUEST FOR ELECTRICAL INSPECTION ��`�
�F�y ' z� ,
'} "� Q Minnesota Board of Electricity k �
y�'� � O��� V �' 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 � S
��
(651) 642-0800 TTYIMRS 1-800-627-3529 wx��v.electricit}�.state.mn.us "�,��s
Describe -using th�ack of t�e white copy if necessary - the work covAed by thi eques�� ��
I SERVICES / POWER SUPPLIES
0 to 200 Am ere $5
Above 200 Ampere $10
ALARM, COMMUNICATION, REMOTE CANTROL, SIGI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITI01
Lighting Retrofit @ $.25 per Fi#ure
Center Pivot Irriqation Boom (� $40
Outdoor Lighting Standard @ $1
Traffic Signal Standard $5
Supplemental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / Outline Li htin $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
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF
I(lil il III li i�i II Iil II ��I II �i� II Iil II li( h ql I I�I
18805283
ivir��rcc
total fee is $20) v� a`��
I insveded the electrical installation described herein on the dates stated:
/-- l(' �l,j
2 MONTHS
Date: Rough-in Inspection Required? ❑Yes No Inspection Other Than Rough-In: eady Now ❑ Wiil Call
/l� U �� r�
� 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
7 3 0�� Cc��s t e, r� /� �,�/
Range
� � I'Y1 �C.) l � l�'1'�i �J
rical Utility Electrical Utility Address
;��_ � i..s'i � � �
rador / Company Name Con1
�J �/� E�� c,, f�! � �'
ng Address (Contractor, Company or Owner Performing Installation)
3� �k� �'�V -s� /� L �
ora9d ia c or Own r Performina Installationl f
Fire No. County
� � i: �< �%�
Please Provide Two (2) Phone Numbers Including Area Code
\ / \ /
PS u #' % �1 �S /h �'�%
�dor License Number Master Electrici or Power imited Technician
� ` O „ /1 �� License Number
� �
J' �S /� /l� 5'�S" �f �.�
lease Provide Two (2) Phone Numbers Including Area Code
(6/� �y� //�° ( )
rv t�.11ov FR_M1f1f11A_15 R 1 Jflfld