P - 77121REQUEST FOR ELECTRICAL INSPECTIO
1;� g�_� _ g 7 g� Minnesota Board of Electricity ���. �.�-�7�
1821 University Avenue Suite S-128, aint aul,rNinnesota St
`�� ""130�� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
Describe -using the back of th white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoor Lighting Standard $1
SERVICES / POWER SUPPLIES Traffic Sipnal Standard na $5
Above 800 Am ere $75
CIRCUITS I FEEDERS
0 to 200 Am ere $5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus na $.50
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
Retrofit @ $.25 per Fi�Aure
'ivot Irriaation Boom a(� $4(
ONE & TWO FAMILY DWELLINGS, EACH UNIT
includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investigative Fee
Reinscection Fee (�D $20
total fee is $20) � p�0
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I hereby ceNTy that I inspected the electncal inslallation described herein on the dates slated:
Special Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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19129790
Date: . Rough-in Inspection Required? ❑ Yes No InspecUon Other Than Rough-In: ❑ Ready Now iii Call
O`� /�'�� You must call the inspector when ready! Date Ready:
I certi(y tnat I am the �'LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
J i (itwitre't Address � A1 ( " �v � �_� City� t � ��
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MN 55304
,� rtning Installa5on)
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Co tractor License Number Master Electrician or Power Limited Techni
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Please Provide Two (2) Phone Numbers Including Area Code
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