P - 77056REQUEST FOR ELECTRIC�L INSPECTION ,... �'�
�s � Minnesota Board of Electricity ��(�� (�a�� �'s �
9 2 6 9 31 0 �g2� University Avenue Suite S-128, Saint Paul, Minnesota 55104 �.'
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us �';�*�
Describe -using the back of the white copy if necessary - the work covered by this request:
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NERAL FEES Outdoor Li hting Standard $1
SERVICES / POWER SUPPL S Traffic Sianal Standard Cil $5
0 to 400 Ampere $25
401 to 800 Am re $50
Above 800 Am re $75
CIRCUITS I FEEDERS
0 to 200 Am ere $5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CANTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL
Lighting Retrofit (� $.25 per Fixture
ONE 8 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
Investiaative Fee
total fee is $20) I NC 1�
I hereby certify that I inspeded the electrical installation descnbed herein on the dates stated: �
RWGH IN �ATE
Se arate Bondin Ins ion $20 �l� �•
Sp2Ci81 IfISp2Cti0f1 $30 p2f HOUf exwReo�nanr�ooNe oni
Special Inspection @ $.31 per Mile
IIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rou h-in Ins ection R uired?
g p eq ❑Yes o Inspection Other Than Rough-In: ❑ Ready Now ill Cail
You must call the inspector when ready! Date Ready:
I certify that I am he�ICENSED CONTRACTOR ❑ COMPANY O OWNER and hereby request inspection of the electrical work at
Job Site Street Address City
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3�°�, ��ea� `�Ci1. Electric ervi
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Sr�rinn I nka Pnrk_ MN
ir' i tu Cont or r Owner e o ing Insta a1
(763) 783-7080
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Contrector License Number Master Electrician or Power Limited Technician
rli n .�.-.. � � . License Number
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