P - 78389REQUEST FOR ELECTRICAL INSPECTION
1 3� 7 3 3 3 tle.0 Minnesota Board of Electricity
� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
, (651) 642-0800 TTY/MRS 1-500-627-3529
www. electrici ry. state. mn. us
Identify the work covered by this request f s��
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR �� �
GENERAL FEES Outdoor Li htin Standard 1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
to 400 Am ere � Su lemental Fee �$20
401 to 800 Am ere �$50 Transtortners u to 10 KVA (� $10
Above 800 Am re�$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transfortner / Power Su for Si ns / Outline Li ' �$5
0 to 200 Am ere �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere �$10 Includes the Service andlor Power Supply up to 500 Amperes, All
ei ec�� cn�e��i iwcerinti pPAA(17F C(1N7Rnl _ SIGNALING Circuits and Two Inspection Trips Each Dwelli Unit � S80 �
:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus f� $.50
ADDITIONS TO THE GENERAL I
TIFAMIIY DWELLINGS (PER UNI'�
3 to 12 Units �$50 Per Unit
Each Additional Unit � $25
OTHER ADDITIONAL FEES
Lighting Retrofit � $25 per Fature
Center Pivot Irtigalion Boom � $40
Manufactured Home Park Lots � $25
Recreational Vehicle Park Sites � $�
�
.L
Fee �
I herebv certifv that I inspected the electrical
IF
���� �«
total fee is $20) �. S �
h
xribed herein on the date.s stated:
wh
�� �y._w.re�'�
"l� '=3
FOR OFFICE USE ONLY
I III111 lilll Ilili 1111i HIII Illll I{IIl Illll Ifll Illl
,�.� �6 �s
�E 1 3 4 7 3 3 3 S�E �/ ��
Requ�D te: Rough-in Inspection Required? es ❑ Na Inspection Other Than Rough-In: ❑ Ready Now II Call
p�s � You must call the inspector when ready! Date Ready:
I certify that I am ihe ❑ LICENSED CONTRACTOR ❑ COMPANY Q�OVfINER and hereby request inspection of the e�ectrical work at:
Job Address (Street, Box, or Route No.) Ciry Zip Code
/3 �S`i ' I� � p� rv�� e, s'i�"�Io� 1
Section Township Range Fire No. ' County
. �� �'�vo.L�.s�
Occu (,f/1•.�JW"x► ^ Q.��/'2. Phone
�/ � � � ,s' �� ��.i�r'^
Power Supplier Address
X� �°� �h�e � v �.r l✓ c� ��,X
Electrical Contrador / Company Name A♦ O CoMractor License Number Master License Number
Y�
Mailing Address (Conh F, Company or Owner Perfortning Installation)
�
Autho' ature (Contractor, Compan er Performing Installation)
EB-00001A43 7/1/2000 � BOAHD OF ELEC7RICRV COPY
none I
? � 3 J' �� 9�'oi J'
INS'THUC710N3 ON BACK OF YELLOW COPY