P - 81569REQUEST FOR ELECTRfCAL INSPECTION
Minnesota Board of Electricity �
1� 0��� 3 5 4� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-OS00 TTY/MRS 1-800-627-3529
www.electricity.state.mn.us
Itlentify the work covered by this request:
❑ NEW $REMODEL ❑ADDITION ❑ REPAIR
GENERAL FEES
SERVICES / POWER SUPPLIES
0 to 400 Am ere �$25
401 to 800 Am re C� $50
Above 800 Am ere (� $75
CIRCUITS / FEEDERS
l 0 to 200 Amoere ��5 l e r n e.+ r
IICATION, REMOTE CONTROL,
ITS OF LESS THAN 50 VOLTS
Device or Apoaratus � $.50
Unit � 9
OTHER
Vehicle Park Sites �
idin9 Insoection � $�
1C�G`t'ii��C/'I�' `�f,C 171�Gt'i
Supplemental Fee � $20
Transformers up to 10 KVA �
Transformers over 10 KVA �
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellin Unit �$8(
Additional Inspection Trios � $20
Fee
total fee is
1 herebvi cerdiv that I inspected the electrical inshallation described herein on the dates stated;
Ron o�ce usE oN�r
� ���ill ��I�� ����� ����� I���I ��� ��I�� �III ����
�4 1 O 5 3 3 5 4 5�E
Request Date: Rough-in Inspection Required? ❑ Yes ❑ No Inspection Other
!`�! /�U� You must call the inspector when ready! Date Ready:
v �
)MPLETED WITHIN 18 MC
.��
� �
IZ S.�u
I certify that I am the [�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the slectrical wodc at: