P - 78333REQUEST FOR ELECTRICAL INSPECTION
1� 3 6 4� 6 � Q Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
p (651) 642-0800 TTY/MRS 1-800-627-3529 - -
www. e lectricity. state. mn. us
Identi(y the work covered by this request:
❑NEW ❑REMODEL ❑ADDITION EPAIR ��11l��' tjLL- Q�'j
GENERAL FEES Outdoor Li htln S ard �$t
RVICES / POWER SUPPLIES Traffic Si nal Standard f� $5
0 to 400 Am re �$25 % Su lemental Fee �$20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10
Above 800 Am re �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li htin �$5
to 200 Am ere �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspectlon Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri s�$20
Each S stem Device or ratus �$.50 Investi tive Fee
ADDITIONS TO THE GENERAL FEES Reins ecfion Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE Q o
3 to 12 Units �$5o Per unit (minimum total fee is $20) dr
Each Additional Unit � $25 F0fl "'�CT°" "� °NL � � �c.t � c jt a �
OTHER ADDITIONAL FEES ��( 's� ���%-
Li htin Retrofd �$.25 er Fixture
Center Pivot Irri tion Boom �$40
Manufactured Home Park Lots � I hereby certify that I inspected the electrical installation described herein on ihe dates stated:
Recreational Vehicle Park SRes � �01�"" ��
S rate Bondin In 'on � $20
S ial Ins ion �$30 r Hour '� "��"�" 7� c r!
S ial In ' n�$.31 r Mile l 7�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
�— -- ---
FOR OFFICE USE ONLY
I+ If !+{`++I+fI � -�' ��l� c�
I IIII�� I�I�� II�II �I�I� ��I�I ���I I��fli �I�I'�II I'!{ ._
�E 1 3 6 4 6 O Q 5� ��'�� � 9�U ��' �d
Date: � Rough-in Inspection Required? ❑ Yes ❑ No Inspectian Other Than Rough-In: Ready Now ❑ Will Call
u� 0 You must call the inspector when ready! Date Ready:
I certliy that I am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Jo Address (Street, Box, or Route No.) City Zip Code
a �- �vD �T' /� � . �/�,(£ .�1'f%��
Section Township Range Fire No. County � ,
/C �i�✓ /?0%
Power Supplier
EI CoMractor / Compan Name
s
Ma�lin ddr ss (Co ctor a
�� i
Authorized Sia om
��U V � 4 Phone
�� 1
Address
Contrador License N�n
� � �JD
er P rfarming Installa ion) ,
i�V /I/I✓. � � �e�r�i.
or Owner Perfortning Installation)
�
BOARD Of ELECTRICRY COPY
Number
��i �.s /�l� .��"�'
Phone
%lo,� `�f� �DD
INSTRUC710NS ON BACK OF YELLOW COPY