P - 76709REQUEST FOR ELECTRICAL INSPECTION �
I������ 4 9 3� Minnesota Board of Electricity o���� �a�� �)O ,p;
1821 University Avenue Suite S-128, Saint Paul, Minnesota 551�
(651) 642-0800 TTYIMRS 1-800-627-3529 www.electriciry.state.mn.us ;�g��
Describe -using the back of the white copy if necessary - the work covered by this request:
GENERAL FEES Outdoor Liahtina Standard (� $1
I POWER
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus a$.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
Lighting Retrofit @ $.25 per FiMure
Center Pivot Irrigation Boom @ $40
Manufactured Home Park Lots @ $
Recreational Vehicle Park Sites (� ;
Traffic Siqnal Standard
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
Investi ative Fee
Reins tion Fee $20
TOTALFEE
(minimum total fee is $20) f3� S�
THIS AREA FOR INSPECTOft USE ONLY
J�%O C la i��-'GcM� O c.� !�c'r(
I hereby certiy that I inspeded the electrical installation desaibed herein on the dates stated:
S ial Inspection $.31 per Mile -�--�---�� Z�/
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTH
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18204933
uaie: Rou h-in Ins ction R uired? ❑Yes o Ins
', g pe eq � pection Other Than Rough-In: ❑ Ready Now Will Call
/�g/U � 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 �rty
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Township � Sectlon Range Fire No. County
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Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
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ElecUical�ty — � Electrical U' ddress ^ /A,\
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Master Electrician or
License Number
or,-company or ryEr Pertorming Installati )
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ontractor or r erforming Installation) Please Provide Two (
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F YELLOW COPY BOARD OF ELECTRICITY COPV
Jumbers Including
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