P - 76485REQUEST FOR ELECTRICAL INSPECTION �
1� 7 Q Z� Q� Q � Minnesota Board of Electricity ;,*;- -
���� V �J 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 wx��ti.electricity.state.mn.us
Descnbe -using the back of the white copy if ne�s�ary_-�the �r� gve,�ed by.�� requflst; �. �..,� _.
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,:-GENERALFEES
SUPPLIES
Z00 Ampere @$10
N�AMUNICATION, REMOTE CONTROL
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Apparatus (cil $.50
Z Units @ �,50 Per Unit
Additional Unit @ $25
OTHER ADDITIONAL FEES
ng Retrofit @ $.25 per Fixture
rr Pivot Irriqation Boom (cil $40
Traffic Signal Standard
Supplemental Fee @ $
Transformers uo to 10
� Transformer / Power Supply for Signs / Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiqative Fee
TOTALFEE �?{}rt!=,�
nimum total fee is $20)
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that I inspected the electrical installation described herein on the dates stated:
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Bondin Ins ection $20 .t�,�._ %� �'t
1S �iOn @$30 pe� HOUf exaiaEO; nenNOOr�=o onre
ts ection $.31 per Mile
'ALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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17�78984
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"'�' I Rou h-in Ins ection Re uired? ❑ Yes .
g p q 7�] No Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
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� - �YOU must call the inspector when ready! Date Ready:
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I certify that I am the L�7 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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I, Jpb Sit@ Sheet Address �� -��Cit ar r.
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Fire No.
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� OwnedOccupant Name �, Please Provide Two (2) Phone Numbers Including Area
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ElecVical UHIitY � �� �� ectrical Utility Address � � � �
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i Contractor / Com an Name �
P Y Contractor License Number� Master Electrician or Power Limited 1
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, Mailinp Address (Contractor, Company or Owner Pertorming Installation)
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A Si re(Contractor or Owner Performing Installation) � Please Provide Two (2) Phone Numbers Including Area
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M9TRUCTIONS ON B4CK OF VEI.I (]W C(]PV Rnnan nc Gi crTOiriTV rnov � .. .......... . � .. .,....,.