P - 76471REQUEST FOR ELECTRICAL INSPECTION k
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� � Minnesota Board of Electricity �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 wwit.e[ectricitv.stute.mn.us
Describe -using the back of the white opy if nece�ss� the ��v�re(�,by�ibiS fq�ug,�t, t; u, :'•�r; �•, _
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FEES
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� Above 200 Ampere @$10 �
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCINTS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus $ 50
ADDITIONS TO THE GENERAL FEES
Standard
Supplemental Fee @ $20
Transformers u to 10 KVA �$10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns ! Outline �i htin $5
ONE & TWO FAMILY DWELLIN�S, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection 7rips Each Dwelling Unit @$80
Additional Insoection Trios na $20
Fee
fIFAMILY DWELLINGS PER UNIT TOTAL FEE ;�i.j z;-�! 7
3 to 12 Units @$50 Per Unit (minimum total fee is $20)
Each Additional Unit @$25 rHis naEa wR u+saecroR usE on�r
OTHER ADDITIONAL FEES
Li tin Retrofit $.25 p2f FiXtUre I hereby certify that I inspected the electncal installation described herein on the dates stated:
Center Pivot Irtiaation Boom (�a $40 Ro�cH w oArE
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� Special Inspection @$ 31 per Mile I I
TN18 FNSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12_MONTHS
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���� j Rough-in Inspection Required? ❑ Yes :� No � Inspection Other Than Rough-In: [�Ready Now ❑Will Call
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_ -_ :'_'_ _ __ _ _ __'j You must call ihe inspector when ready! _ __ j_Date Ready: _
I certify that I am the [� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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, Job Site Street Address � �� City �. .. 1 �. ! ��'}i h; ��'�; i; i' i
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�'�, Township � I Section I Range Fire No. I� County
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' OwnedOccupanl Name ��, Please Provide Two (2) Phone Numbers Including Area Code
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' Electrical UtiFty -TElectrical Utility Address
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Contr�ctor % Company Name � Contractor License Number I Master Electrician or Power Limited Technician I
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� Ma�ling Address (Contractor Company or Owner Performing Installatwn) I� � �
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�, Authonz9d S' nature (Contrac[or or Owner Performing Installation) Please Provide Two (2) Phone Numbers Including Area Code
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