P - 79852REQUEST FOR ELECTRICAL INSPECTION
:1 3 0 8 3 4 2�� Minnesota Board of Electricity
� � i821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-500-627-352
www.electricity.state.mn.us 6
Identify the work covered by this request:
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR (/� v �-- � � ( C !
GENERAL FEES Outdoor Li tin Standard �$1
SERVICES I POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to S00 Am re �$50 Transformers u to 10 KVA �$10
Above 800 Am re �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su I for S' ns / Outline Li htin �$5
0 to 200 Am ere �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Ci�cuits and Two Inspection Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Tri (� $20
Each S stem Device or ratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ection Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units �$50 Per Unit (minimum total fee is $2
EBCh Addi60�e1 Unit �$25 FON INSPECTOq USE ONLV
OTHER ADDITIONAL FEES
Li htin Retrofit �$25 r Fxture
Center Pivot I' ation Boom �$40
ManufaCtUrBd Hom2 Pa�ic LotS �$2 1 hereby cerlity that I inspected the elechical installaGOn des�xibed herein on ihe dates st�d:
Recreational Vehicle Park Sites � c `�"�"'" °ATE
Se arete Bondin In 'on � $20
S ecial Ins ection �$30 er Hour F""""��"0N DA7E
S ial Ins ection �$.31 er Mile �'Z --CTZ
_ THISJNSTALLATION MAY BE ORDERED DISCONNECTED IF COMPLETED WITHIN 18 MONTHS
FOR OFFlCE USE ONLY
I lllill lfl��lllll lll�� ll4ll llll} 1i1111111� llil lfll ���/
� 1 3 n B 3 4 Z 3� ��7/8p �Q�S�
Request Date: Rough-in Inspection Required? ❑ Yes Inspection Other Than R gh-In: dy Now O Will Call
You must call the inspector when ready! Date Ready: / Q�
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job di�qss�SUeet, , or Ro e .) CitY Zip Code
�. �y <a
S ion Township Ra Fire No. Counry
Occu �.� +
I ,! Phone � � w �
/l 1 ! �
K.. ,►
Power Supplier Address
E�ect ' onVactor / Co arry Contractor License Number Mester �cense Number
� �l/% � �� �i�7� L.L �� �7C.�
Mailin� ss (ConUador, Company or Owner Pertortning Installation) '
� a�� � �, CS'� �
Autho ' ed 'gnature dor, Company or Owner Perfortni Installation) php�
' �"�'�� � 2 �c%'��P �C�
=&00001A-73 7/1/2000 BOARD OF ELECTpICITY COPY INSTRUCTpNS ON BACK OF YELLOW COPY