P - 76470REQUEST FOR ELECTRICAL INSPECTION
1�� O 1- 9 0 3 2❑ Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 wiviti�.electricite.slute.mn.us
pescribe -using the back of the white copy if ne�s��^ the yv��,p��,by �ii,� re,pue,st� ,� `. , .�,
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`GENERAL FEES Outdoor Lighting Standard @ $1
SERVI S! POV,�f�UPPLIES � Traffic Sianal Standard C�a $5
401 to 800 Ampere $50 Transformers u to 10 KVA $10
Above 8�0 Am re $75 Transformers over 10 KVA $ 20
UITS I FEEDERS Transformer I Power Su I for Si ns I Outline Li htin $5
0 to 200 Am ere $5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes the Service andlor Power Supply up to 500 Amperes, All
tM. COMMUNICATION. REMOTE CONTROL SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS OF LESS THAN 50 VOLTS
iystem DeviCe or Apparatus @ $.50
ADDITIONS TO THE GENERAL FEES
ILY DWELLINGS (PER UNIT)
Unit
Center Pivot Irrigation Boom @
1Aanufactured Home Park Lots (
Recreationai Vehicle Park Sites
Fee
TOTAL FEE ;'(;,
total fee is $20)
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I insoected the elecMcal installation descnbed herein on the dates stated:
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SpCCi211RSp9Cti0f1 $30p0fH0Uf � ExviaEO�n9nr�oon�EC onre
Speciai inspection @ $.31 per Mile
TH181NSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: � Rou h-in Ins ection Re uired? ❑ Yes '
g p q .�] No 'i Inspechon Other Than Rough-In: [�Ready Now ❑Will Call
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�"'' `"'° j�"�� � You must call the inspector when ready! Date Ready:
I certify that I am the f� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Sde Sireet Address �; Cit - -�-,t: � e: R. n
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Range
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' Ownar/Occupant Name �� '� Please Provide Two (2) Phone Numbers Including Area Code
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i Electnd Ulility i Electrical Utility Address
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' Contractor / Company Name � � i Contractor License Number i Master Electrician or Power Limited Techni�
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i MaJing Address (C�o'ntractor CoTmpany o{r�� Owner Performmg Installation) -� � �
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Authorisad S' nature (Contractor or Owner Performing Ins[allation) Please Provide Two (2) Phone Numbers Including Area Code
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