P - 76577REQUEST FOR ELECTRICAL INSPECTION � � �'�,
1� 9 2 4- 5 3 6� Minnesota Board of Electricity �; �
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1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104 �
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us � ��
Describe -usin the back of the white copy if necessary - the work covered this request;
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GENERAL FEES Outdoor Lightin Standard @$1
SERVICES / POWER SUPPLIES Traffic Signal Standard $5
0 to 400 Ampere @$25 Supolemental Fee na $20
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus $.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lightin Retrofit @ $25 per FiMure
Center Pivot Irri ation Boom $40
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites (� S5
5 ecial Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNE
I IIII II II) II III II III II III II III II (II II III II � I�I�
1 9 2 4 5 3 6 4
� Transformer / Power Supply for Siqns / Outline Liqhtin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiqative Fee
TOTAL FEE G Q
total fee is $20) ,�� ��
I hereby certiy that I inspeded the electncal installation described herein on the dates stated:
ROUGHIN ppTE
FAIL'lNSPECTIIXJ , � DATE
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E%PIREDIA94NDONED pq�
CTED IF NOT COMPLETED WITHIN 12 MONTHS
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Rough-in Inspection Required? ❑ Yes �No InspecGon Other Than Rough-In. dy Now ❑Will Call
t� You must call the inspector when ready! Date Ready:
I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Street Address � � ��
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Electrical � i y ddress
npany Name Contractor License Nun
(Contrector, Company or Owner Performing Installa6on)
3440 Kil
ature (Contractor or Owner Performing Installation) Please I
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iN BACK OF Y L Y BOARD OF ELECTRICITV COPY
Numbers I
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Master Electrician or
License Number
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Technician I