P - 77192REQUEST FOR ELECTRICAL INSPECTION `'���'�'�
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1� v 10 � 5 71 � Minnesota Board of Electricity KF �„
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 '�., -�
, . (651) 642-0800 TTY/MRS 1-800-627-3529 www.elec�ricity.state.mn.us ��
Describe -using the baci f the white co y if,necessary - the work covered by this request:
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GENERAL FEES Outdoor Lighting Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Amoere lo? $25 Suoolemental Fee na $20
iM, COMMUNICATION, REMOTE CANTROL, SIGNALING
:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Apparatus an $.50
Center Pivot Irrigation Boom �
Manufactured Home Park Lots
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 Ins ection Tri s $20
Investi ative Fee
Reins ction Fee $20
TOTAL FEE
(minimum total fee is $20)
THISAREA FOR INSPECTOR USE ONLV
I hereby certiry that I inspeded Ne elecUical installaGon descnbed herein on the dates slated:
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THIS INSTAILATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rou h-in Inspection Re uired?
�_��� g q ❑ Yes o Inspedion Other Than Rough-In: ❑ Ready Now ❑ Will Call
You must call the inspector when ready! Date Ready:
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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Please Provide Two (2) Phbne Numtiers I
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Utility Address
M8St8f EIECtlICIBfI Of
License Number
or O� r Pertorming Installation) Please Provide Two (2) Phone Numbers Including
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