P - 80165REQUEST FOR ELECTRICAL lNSPECTION
�_ 2 6 6 7 5 � v�P � Minnesota Board of Electriciry '�
� � � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
;s����° (651) 642-0800 TTY/MRS 1-800-6273529
www.electricity.state.mn.us � �
Identify the work covered by this requesC �, �)r17/)
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❑ NEW ❑ REMODEL ❑ ADDITION REPAIR � (�
GENERAL FE S Outdoor Li h in tandard �$1
SERVICES / POWER SUPPLIES Tra�c Si nal Standard �$5
0 to 400 Am re �$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10
Above S00 Am ere �$75 Transformers over 10 KVA �$20
CIRCt11TS / FEEDERS Transtormer / Power Su I for Si / Oulline Li htin �$5
0 to 200 Am ere (� $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re(� $10 Includes the Service and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Unit f� $80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Tri �$20
Each stem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins on Fee �$20
MULTIFAMILY DWEILINGS PER UNI TOTAL FEE
3 to 12 Units �$50 Per Unit (minimum total fee is $20)
EaCh Additional Unit �$25 FOP N�57ECTOq USE ONLY
OTHER ADDITIONAL FEES
Li htln Retrofit �$25 er Fixture
CeMer Pivot I' ation Boom d$40
ManUfaCtur2d HOm@ PBfk LOiS �$25 I hereby certify that I inspected the electriql installatlon described herein on the dates stated:
Recreational Vehicfe Park Sites �$5 fl01�"" DA7E
Se arete Bondin Ins ion �$20 �
S ecial Ins ection �$30 r Hour F'"""'u"`�70N DA7E
S ecial Ins ection �$.31 er Mile � �^ 3"' GL
THIS INSTALLATION MAY BE ORDERED DISCONNECTE T COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONIY
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Request Date: 'D� Rough-in Inspection Required? ❑ Yes o Inspection Other Than Rough-In: eady Now ❑ Wfll Call
� You must call tbe inspector when ready! Date Ready:
I certiiy that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
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Occu Snt ,
Power p er Address
E ' I Contractor / Company Name
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ailinp Address (Contractor, Company or Owner Performing Install
Phone
License Number
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OF ELECTHICRY COPY IN37FIUCTIONS ON BACK OF YELLOW COPY