P - 81842REQUEST FOR ELECTRICAL INSPECTION
� � � Minnesota Board of Electricity '�
1�������� p, `�f�� (6 1�) 642 OS 0�TTY/MRS�1 00 627 3529�au1, Minnesota 55104
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� www.electricity.state.mn.us
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Identity the work covered by this request: ��,Re !4 ! 2�� p �
❑ NEW ❑ REMODEL ❑ADDITION ❑ REPAlR
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traftic Si nal Standard �$5
0 to 400 Am re �$25 Su lementat Fee �$20
401 to 800 Am ere �$50 Transformers u to 10 KVA �$10
Above 800 Am re �$75 7ransformers over 10 KVA d$20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li htin �$5
0 to 200 Am ere �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes ihe Service and/or Power Suppty up to 500 Amperes, AH
ALARM. COMMUNICATION. REMOTE CONTROL. SIGNALING Circuits and Two Inscection Trips Each Dwellina Unit �$80
�UITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins 'on
Each System Device or Apparatus �$.50 Investigative Fee
ADDITIONS TO THE GENERAL FEES Reinsoection Fee �
Each Additional Unit
Retrofit � $25 per Fixture
Pivot Irriaation Boom � S40
I herebvi cerli(v thet I insoected the eiechical installaati�on
Inspection � $2(
� $30 per Hour
� 5.31 cer Mile
FOR O E USE ONLY
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total fee is
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Request Date: Rough-in Inspection Required? ❑ Yes �J No Inspecbon Other Than Rough-In: �Ready Now U Wdl Cell
S� 9�� � You must call the inspector when ready! Daie Ready:
I certi(y that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspeclion of the elecUical work at:
Job Address (Street, Box, or poute No.) City Zip Code
.S�y/ a2 ���-..ST lY E_ �/?-1 D G e
Section Township Range Fire No. County
�NO �
Occu�nt Phone
�o►, n� lak� 288 �� -�i-7�� Z
Power Supplier Address
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Electrical Contractor / Company Name Contractor License Number Master L'xense Number
i�T-S' E'GEc1''lZ�C �,r4-0 8
Mailing Address (ConVador, Company or Owner Perfortning Installation)
8%-6 025'7�fi�e !� �% 2��'►n. . �'!'1 � . SS39�
Aulhorized Si-�ntractor, Compeny w Owner Pertorming Installatio Phone
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E&OOOOtA-13 7/1/2000 BOAHD OF ELEC7RICRY COPY INSTRUCTIONS ON BACK OF YELLOW COPY