P - 76469REQUEST FOR ELECTRICAL INSPECTION
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� J� ❑ Minnesota Board of Electricity �r- �'
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-6273529 wx°x�.electricity.state.mn.Us
Describe -using the back of the white copy if n�e�ar�ithe ��C�e�.byrEtij� f��est: � r�� � F;� i�
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$ERViCES! POWfR SUPPUES
0 to 400 Ampere $25
4Q1 to 800 Ampere $50
Above 800 Am re $75
CIRCUITS I FEEDERS
0 to 200 Am re $5
Abpve 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGI
fIRCUITS, CtRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADD�TIONS TO THE GENERAL FEES
MULTIF6Uu14LY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
{in Retrofit $.25 per Fixture
Certter pivot Irriaation Boom an $40
Outdoor Liqhtinq Standard
Supplemental Fee @ $20
Transformers up to 10 KVA @$10
Transformers over 10 KVA $ 20
Transformer / Power Sup I for Si ns / Outline Li htin $5
ONE & TWO FAMILY DWELIINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Fee @ $20
TOTAL FEE i'!_ �
nimum total fee is $20)
that I inspected the electrical installation described herein on the dates slated:
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ial Inspection @ $30 per Hour `""'"`° "°""°""`� °"'
Special Ir�spection @ $.31 per Mile
THI$ ttfSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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� ���� � Rough-in Inspection Required? ❑Yes }0 No , Inspection Other Than Rough-In: [�Ready Now OWill Call
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:' i You must call the inspector when ready! Date Ready:
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I cert�fy that I am the L�'] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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Job SAe Street Address i City a_ �� A�"��_� •j' +�,� r�: �( "`�?
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il Township
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' OwnerJOccupanqt Name
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Section I Range
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��, Please Provide Two
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E�ectrica� Utility r I Electrical Utility Address
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�� Conhactor / Company Name . Contractor License Numbe� I Master Electrician or Power Limited Techni
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Mailing Addreas (Contractor, Company or Owner Performing Installation)
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�-AU�thyo�izqd Si nature (Contractor or Owner Performing Installa[ion) Please Provide Two (2) Phone Numbers Including Area Code
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