P - 77642RE(�UEST FOR ELECTRICAL INSPECTION
1 3 4 7 5 4 8 Minnesota Board of Electriciry
� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 -
www.electricity.state.mn. us
Identify the work cover tiy this request:
❑NEW MODEL ❑ADDITION ❑REPAIR L • �'�""� " � �� L � L� I �
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am ere �$50 Transformers u to 10 KVA �$10
Above 800 Am re �$75 Transformers over 10 KVA �$20 ''
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li htin $5
0 to 200 Am ere �$5 ONE & TWO FAMILY DWELIINGS, EACH UNIT
Above 200 Am ere (� $10 ncludes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALIN Circufts and Two Inspection Trips Each Dwelling Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Addi�onal Ins 'on Tri s�$20
Each S stem Device or A ratus �$.50 InvesT ative Fee
ADDITIONS TO THE GENERAL FEES R� ion Fce �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 units �$5o Per unit (minimum total fee is $20) '
Each Additi0nal Unit � $25 `OH1N�CT0R "� °NiV
OTHER ADDITIONAL FEES
Li htin Retrofit �$.25 er Fixture
Center Pivot Irri ation Baom �$40
Manufactured Home Park Lo�s �$25 I hereb certily that I inspected the electrical installation described herein on the dates stated:
Recreaiional Vehide Park Sites �$5 P01GN1N DA1E
Se arate Bondin Ins ion �$20
Cneni�l Incnd.}inn G71 CM nnr LJro�r Fl��E�� l� o ORTE
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF
FOR OFFICE USE ONLY
{ IIlill IIIII IIf811111 lIIII Illii IIIII IIIII illl INI
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) WITHIN 18'MONTHS
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Request Dat : Rough-in Inspection Required? ❑ Yes o Inspeclion Other Than Rough-In: ❑ Ready Now�ill Call
l� f S Q� 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:
Job Address (Street, Box, or Route No.) City Zip Code
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Section Township Range Fire No. County
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Electrical Co tractor / Company Nam
Mailing Address (Co trador, Co ny or Own
Author d Signature (Contractor, C any or
E -13 7/1/2000
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icense Number Master License Number
Installation) P on
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1RD OF ELECTRICfTY COPY IN5TRUC710NS ON BACK OF YELLOW COPY