P - 79724' REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Eiectricity � "
�� 2 2 7- 3 61 ��9e 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY{MRS 1-800-627-3
www.electricity.state.mn.us '�'
Identity the work covered by this request: �---�—�
❑NEW ❑REMODEL ❑ADDITION ❑REPAIR C
GENERAL FEES Outdoor Li hti 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 Transtormers u to 10 KVA �$10
Above 800 Am ere �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su for Si ns i Outline Li Min (� $5
ALARM, COMMUNICATION, REMOTE CONTROL, SIGI
CIRCUITS, GIRCUITS OF LESS THAN 50 VQITS
Each S stem Device or A� aratus @$.50
ADDITIONS TO THE GENERAL FEES
Each Additional Unit (� $25
OTHER ADDITIOP
Liahtina Retrofit � $25 oer Fixture
Recreational Vehicle Park Sites �
Seoarate 8ondina Insoection � �
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Inc{udes the Service andlor Paxer Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellin Unit �$80
AddRional In ion Tri s�$20
Investi ative Fee
Reins ection Fee � $20
TOTAL FEE
(minimum total fee is $20
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I herebvi cerMv Nat I insDected the electrical installation described herein on the dates stated:
FOp OFFICE USE ONLY
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Request Date: Rough-in Inspectlon Required? ❑ Yes ❑ No Inspection Other Than
/-�D -aa You must call the inspec[or when readyi Date Ready:
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby
Job Address (Street, x, or Route No.)
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Section Township Range Fire No. Counry /
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inspection of the elechical work at:
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Power Supplier Address
Ele�trj�L��opjr�tpr papy ^I^. ��I,A• Contractor License Number Master License Number
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Authorized Signature (Con , pany or Owner Perf rming Installation) Phone
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EB•OOOOtA-13 7/1M000 BOARD OF ELECTRICRY COPY INSTRUCTIONS ON BACK OF YELLOW COPY