P - 77041REQUEST FOR ELECTRIC,QL INSPECTION �
QQ Minnesota Board of Electricity ('') �./�7 �-� �
1�:iJ V�- 8 9 3�❑ 1821 University Avenue Suite S-128, Saint aul, inri�s�55'�04'�
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(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us �<�
Describe -using the back of the white copy if necessary - the work covered by this request:
GE L FEES Outdoor Lighting Standard @$1
401 to 800 Am ere $50
Above 800 Am re $75
CIRCUITS / FEEDERS
0 to 200 Am re $5
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITI01
Liqhtinq Retrofit a(i $.25 per Fixlure
Traffic Signal Standard $5
Sup lemental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns I Outline Li htin $5
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
Investigative Fee
TOTAL FEE I
total fee is $201 �(�+ .
I hereby certiTy that I inspected ihe elecUical installalion described herein on the dates stated: (
'- 7-�5� �
S ecial Inspection $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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�Date: Rough-in Inspectlon Required? ❑ Yes Q�Jo Inspection Other Than Rough-In: 0 Ready Now �Nill Call
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l( '4 �► .� You must call the inspedor when ready! Date Ready:
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I certify that I am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
rJOb Site Street Address City
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MN 55432
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License Number