P - 76496REQUEST FOR ELECTRICAL INSPECTION �T"` r
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� � ❑ Minnesota Board of Electricity k �„
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �`
(651)642-0800TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us ;��
Desc '-using the ck of the white wpy' is �ecessary - the work cov ed by t is r st:
--Q e� c. Q U o rY1 �c g e� C��� � C'--7a v�w c P
0 to 400 Ar
401 to 800
Above 800
CIRCUITS / FEE
0 to 200 Ar
RM, COMMUNICATION, REMOTE CONTROL, SIGNALING
;UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
TIFAMILY DWELLINGS PER UNIT
3 to 12 Unfts @$50 Per Unit
Center Pivot Irrigation Boom C
Manufactured Home Park Lots
Recreational Vehicie Park Site:
Supplemental Fee � $20
Transformers u to 10 KVA a$10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns I Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investigative Fee
Reinspection Fee a(� $20
i�iw�rtt
total fee is $20) ��' �.�
I inspected the electrical installation described herein on Ne dates stated: �
� — 5� 2S� � � I
Special Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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��//° � 1 Rough-in ion R ired? es ❑ No Inspection Other Tha Rough-In: Ready Now ❑Will Call
�(J v You m t c�t�l tl(e pS when ready! Date Ready: `� `
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site�et� ress � � � � � City � �' � � �
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Township Section ge Fire No. Coun
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Owner�/,O� pa�t Name PI Provide Two ( Phone Nu bers InGudin Area Code
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Etectrica Utility Elec[n I UtilityAddress
r / Company Na��
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Master Electrician or
License Number
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or Owner Performing Installation) Please Provide Two (2 hone Numbers Including
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COPY BOARD OF ELECTRICRY COPV cc n