P - 79810REQUEST FOR ELECTRICAL INSPECTION
1:312 6 6 8 Minnesota Board of Electricity �
� � '° 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
��� (657) 642-0800 TTY/MRS 1-800-627-3529
' www.electricity.state.mn.us ' '
Identity the work covered by this request: �' E,'fjyv� #� 3t� S(pd ` � �e1"
❑ NEW ❑ REMODEL ❑ ADDITION �1.REPAIR
GENERAL FEES Outdoor Li htin Standard �$t
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am re �$25 Su lemental Fee �$20
401 to S00 Am re�$50 Transformers u to 10 KVA (� $10
Above 800 Am ere (� $75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer I Power Su for Si ns / Outline L' htin �$5
0 to 200 Am ere �$5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere �$10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Add'Rional Ins ion Tri s�$20
Each S stem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ion Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units �$50 Per Unit (minimum total fee is $20)
Each Additional Unit (� $25 co� �"S"E"°" us� °"`�
OTHER ADDITIONAL FEES N�-/-r �Z' z"°�'
U hti Retrofit �$25 er Fixture
Center Pivot Irri ation Baom (� $40
Manufactured Home Park Lots �$25 I hereby ' that I inspec�ed the e�eclrical instailadon desaibed herein on the dares slated:
qOUGlI IN ��
Recreational Vehide Park SRes � $5
Se arate Bondin Ins ection �$20
S ecial Ins ection �$30 er Hour """ ��' ��
S ial Ins �on �$.31 r Mile ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
For� oF� use oN�r
i 1111I! lilll li�il filll Illli IIII� lil11 lil�! lill lll!
b���
� 1 3 1 2 6 6 S 5* � aQ�Jr�
Request Date: Rough-in Inspection Required? ❑ Yes o Inspection Other Than Rough-In: eady Now ❑ Will Call
' Z—Z — You must call the inspector when ready! Date Ready: —(J"
I cer6fy that I am the [j�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electri�l work at:
Job Address (Street, Box, or Route No.) City Zp Code
— �=' r ..�, a—ri�t �
Section Township Range Fire No. Coun
.� 0 � � O l�-�
Occu� Phone _
9 -
Power Suppiier
�. �C. Ls � �-/ D� ��J `a �1
Electrical Contractor / Company Name Contractor License Number Master License Number
� ��
Mailing Address (Contractor, Company or Owner Perfo ing Installation)
b�i �10 - �l ��h. Yr� � 4-1
Authorized ignature (Contra er Performing Installation) Phone
I 7G 3 - �33a�
EB-00001 A-13 7/7/2000 � BOARD OF ELECTAICRY COPY INSTRUCTIONB ON BACK OF YELLOW COPV