P - 80442REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electriciry "°�
�� 1 8 O� 8 3 5 ��� E 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� �;, ,�_ (651) 642-0800 TTY/MRS 1-800-627�529
` www.electricity.state.mn.us `' '
Identify the work covered by this request: �--�—�
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR .Q�j �1���/s/"(
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES I POWER SUPPLIES Traffic Si nal Standard �$5
401 to S00 Ampere � $50
Above 800 Ampere � $75
�UITS / FEEDERS
0 to 200 Ampere � $5
Above 200 Ampere � $10
RM, COMMUNICATION, REMOTE CONTROL,
�UITS, CIRCUITS OF LESS THAN 50 VOLTS
MULTIFAMILY DWELLINGS (PER
3 to 12 Units �$50 Per Unit
Each Addilional Unit � $25
Manufaclured Home Park Lots �
Recreational Vehicle Park Sftes �
Su Iementai 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 andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellin Unit �$8(
Addfional Inspection Trips � $20
Investiaative Fee
I hereby cerlity that I
total fee is
� I Special Inspection �$.31 per Mile � � ��—
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI
FOR OFF�E USE ONLY
I IIIIII IIIII II1II INII IIII{ lllll 411I! Il�ll �If11111
herein an the da�s s�ed:
�i�` ��-`�
18 MONTHS
* 1 1 6 D g 3 S 9� ,Q_,�%�� ���5�
Request Date: Rough-in Inspection Required? ❑ Yes ❑ No Inspection Other Than Rough-In: eady Now ❑ Will Call
�D �� �D/ You must call tlie inspector when readyl Date Ready:
I certify that I am the ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrk:al work ffi:
Job Address (Sheet, x, or Route No.) City—�-_ Zip Code
�33 - oZ `/a S-� �.��
Section Township n Fire No. County
�I9
Occupant Phone
7G 3 'S"7a -
Power Supp Address
Electrical Contrac[or / pany ame _ _ Contrac[or License Number Maste_ License Number /
� i
��
EB-OOOOtA-13
�n�t�Irie�'�Nortning Installation)
N 5 4��
or, Company or Owner P rf ing Installation)
BOARD OF ELECTAICRY COPY
' /�/-SC�S�U I
INS7RUC710NS ON BACK OF YELLOW COPV