P - 78403' c REQUEST FOR ELECTRICAL INSPECTION � �
�� 4 9 7�� U O � Minnesota Board of Electricity -
1621 University Avenue Suite S-128, Saint Paul, Minnesota 55104
��-�..�� �� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW EMODEL ❑ ADDITION 0 REPAIR Describe -using the bac of the white copy if necessary - the work covered by this request:
� �.,.05 � `1 i-1- '% � i��
GENERAL FEES Outdoor Li htin Standard $1
' SERVICES I POWER SUPPLIES Traffic Siunal Standard C� S5
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus (a� 8.50
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$60
Additional Insoection Trios � $20
Investi ative Fee
Reins tion Fee $20
TOTALFEE I�
(minimum total fee is $20) �[ �d
THIS MEA FOR INSPECTOR USE ONLY
I hereby ceAiy Mal l inspected the electrical installa6on descri6ed h�n on tlie da�s stMed:
OTHER ADDITIONAL FEES �`
Li h6n Retrofit $.25 r Fiztu�r�e/�
Center Pivot Im ation Boom yYU RIX1Ci11N
Manufactured Home Park Lats S •
Recreational Vehicle Park Sites • F'"°` `a�c"°"
arate Bondin Ins tion $20
S ial Ins 'on $30 r Hour �D'"BMOO
S ial Ins tion $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DiSCONNECTED IF
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60MPLETED WITHIN 12 MONTHS _
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' Request Date: Rough-in InspecGon Required? ❑ Yes No Inspedion Other Than Rough-In: ❑Ready Now Wdl Cell
�,� �� You must call the inspeclor when ready! Date Ready:
I certify tt�at I am the �ICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of the electrical wak at: