P - 77420REQUEST FOR ELECTRICAL INSPECTION
1 3 4 7 5 3 4 Minnesota Board of Electriciry
� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 - _
www. electrici ty. state. mn. us
Identity the work covered by this request:
-s' '� o-c �i �i � -P r e � � � �S
❑ NEW ❑ REMODEL ❑ ADDITION REPAIR
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Tra�c 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 for Si ns / Outline Li htin �$5
0 to 200 Am re �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service ancUor 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 Additional Ins ion Tri s�$20 �
Each S stem Device or A ratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Rein �on Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Unifs �$5o Per Unit (minimum total fee is $20) �—�
Each Additional Unit � $25 F°" "�s"E°T°" "SE °"�v
OTHER ADDITIONAL FEES
Li htin Fetrofit �$25 er Fixture
Cerner Pivot Irri ation Boom �$40
M8nUf3CtufBd Home Paiic Lots �$25 I hereby cert' that I inspected the electrical installation described herein on the dates stated:
Recreatanal VehiGe Park Sites �$5 101G"'" DA7E
Se rate Bondi I ion �$20
S ial Ins ection �$30 r Hour F'"°L'"�°"°"' � �°�''�
S ial In ' n�$.31 r Mile ��`�� Z�"' "
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY
� iii��i ii»i ii��i ���ii �iii� i�iii ��ii� iii» iii� iiii , � , �; � o z �� �. � �
�E 1 3 4 7 5 3 4 8�E ��
R�9I �est Date: Rough-in Inspection Required? ❑ Yes - o Inspedion Other Than Rough-In: Ready Now ❑ Will Call
``�1 �� You must call the inspector when ready! Date Ready:
I certify that I am th�ICENSED CONTRACTOR OMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
� �P 3 �✓ l� Cl: � � L�C S�` ��
Section Township Range Fire No. Counry �
Occupa
v� � �
Power Supplier �
C�
Elect ' 1 �ntractor /
L��
Mailing Address (Con1
�
Addreas
Phone
i G '� -� �'- 7
�me �'.S��l��v I Contrector license Nu r
��A�Q) �
npany or ner Perforrpi Installation)
e� , h '� M �
', Co pan or O�yp rfortning Installation) I
�
- BOARD OF ELECTHICRV COPY
Master License Number
�
INSTAU ONS ON ACK OF YEILOW COPY