P - 78368REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity ` `
1������� Q �� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� (651) 642-0800 TTY/MRS 1-800-627-3529
` www.electricity.state.mn.us
IdentiTy the work covered by this request +�S ���` RE���G�,� $�`�yµTS � N Q/�$/�„��rr
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR y(�.S' A�,`, $;�ph � D � �L M w O R�GIQ.�' � r
GENERAL FEES Outdoor Li htin S ndard �$1
SERVICES I POWER SUPPLIES Traific Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am ere �$50 Trensfortners u to 10 KVA �$10
Above S00 Am ere �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su for Si ns / OuUine Li htl �$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
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuiis and Two Inspection Trips Each Dwellin Unft �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Tri �$20
Each S tem Device or A ratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ection Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE 5 e
3 to 12 Units � S50 Per Unit (minimum total fee is $20) d`�-�
Li htl Retrofit �$25 r FixWre '
Center Pivot Irri ation Boom �$40
Manufactured Home Park Lots �$25 I hereby ce ' that I in the eleqrical instellaBon descnbed herein on tlre detes slffied:
Recreational Vehicle Park Sites �$5 flq101'" �j ��
Se arate Bondi Ins ion �$20 ``-3 ^�3
S ecial Ins ion �$30 r Hour `�"'` "'�`�'701 �� ��C,
S ial Ins ection �$.31 er Mile �`
THIS INSTALLATION MAY BE ORDERED DISCO NECTED IF NOT COMPLETED WITHIN 18 MONTHS
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FOR OFRCE USE ONLY �
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Request Date: Rough-in Inspection Required? Yes ❑ No tnspectlon Other Than Rough-In: ❑ Ready Now ill CaN
g� � 0� You must call the inspector when readyl Date Ready:
I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electricai work at:
Job Address (Street, Box, or Route No.) City TaP Code
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Section Township Range Fire No. County
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Power Supplier Address
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Electrical Contrador / Company Name Contracror License Number Master License Number
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Mailing Address (Contractor, Company or Qwner Perfortning Installation)
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Authorized Signature (Contractor, Company or Owner Performing Installation) Phone
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E&00001 A-1 7/1 BOARD OF ELECTRICRY COPY INSiFtUCTIONS ON BACK OF VEILOW COPY