P - 78422(�c REQUEST FOR ELECTRICAL INSPECTION
1����� J V O � Minnesota Board of Electricity � -
O���� 1821 University Avenue Suite S-128, Saint Paul, Minnesota�5510
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricitystate.mn.us
O W QEMODEL ❑ QDDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
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GENE L ES Outd r htin Standard $1
SERVICES / POWER SUPPLIES Traffi ' nal Standard $5
0 to 400 Am re $25 Su lementai 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 I FEEDERS Transformer I Power Su I for Si ns I Outline Li htin $5
0 to 200 Am re $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes ihe Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING CirouiLs and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Addi6onal Ins fion Tri $20
Each S stem Device or A atus $.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reinscec6on Fee �$20
3 to 12 Units �$50 Per Unit
Each Addi6onal Unit @ $25
OTHER ADDITIONAL FEES
Liahtina Retrofit � 5.25 oer Fixture
Mile
�Y BE
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1 4? 4 9 6 0 0
TOTAL FEE I
(minimum total fee is $20) � y�
TNIS ARFA FOR Il15PECTOR lISE ONLY
I hereby cerdry Mat I inspecBed the electiical installa�on described haein on the dates sfaBed:
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Req t Date: Rough-in Inspection Required7 ❑ Yes �lo Inspection Other Than Rough-In: ❑Ready Now�Will Call
O3 You must call the inspeclor when ready! Date Ready.
I ce ' that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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ON BACK OF YELLOW COPV BOARD OF ELECTRICITV CAPY EB-00001M14 8.1. 2002