P - 79865� , REQUEST FOR ELECTRICAL INSPECTION
° � Minnesota Board of Efectricity
1� 2 3 2- 7 9 9 �� i82� University Avenue Suite S-128, Saint Paul, Minnesota 55104
m��,='"� (651) 642-0800 TTYlMRS 1-800-627-3529
� www.electricity.state.mn.us �'7'J% j
Ident the work covered by this request: �� e �v� �✓� � 1
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❑ NEW ❑ REMODEL ❑ ADDITION REPAIR
GENERAL FE S Outdoor Li htin Standard �$1
SERViCES / POWER SUPPLtES Traflic Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10
Above S00 Am ere �$75 Transformers overl0 KVA �$20
CIRCUITS ! FEEDERS Transtortner I Power Su I for Si ns / OuUine Li hGn �$5
0 to 200 Am re �$5 ONE & TWO FAMILY DWELIINGS, EACH UNIT
Above 200 Am ere �$10 Inciudes the Service and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS AddRional In ion Tri s�$20
Each Svstem Device or A�oaratus �$.50 Investigative Fee
FEES
IFAMILY DWELLINGS (PER UNIT)
to 12 Units �$50 Per Unit
ach Additlonal Unit � $25
OTHER ADDITIONAL FEES
phtinq Retroffi � $25 per Fixlure
enter Pivot Irrigation Boom � $40
anufaclured Home Park Lots � $25
ecreational Vehicle Park Sites � $5
Fee �
(minimum total fee is $20
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f insoected the electrical instafYation described herein on 1he
5 eciai ms on ��:w er nour - �y I
Suecial Insoection �$ 31 aer Mile ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY
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Requesi Date: Rough-in Inspection Required? ❑ Yes �No Inspection Other Than Rough-In: Ready Now 0 Will Call
CQ��`►' � You must call the inspectorwhen readyl Date Ready: lQ—'.. �0 }�
I cerMy that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Address (Street, Box, or Rout No.) Ciry Zip Code
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Sec[ion Township
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ElecVical Contractor / Company Name
Mailing Address (Contrador, Company or Owner
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Autho ' Signa ( ntSpctor, peny or O
/ County
Phone
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License Number Master License NumG
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�u ,rn�-. 55�3�
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BOAflD OF ELECTHICITY COPY .INSTRl1CT10NS ON BACK OF YELLOW COVY