P - 77530REQUEST FOR ELECTRICAL INSPECTION '�
����� m� � 1 0 � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using t�e back of the white copy 'rf necessary - the work covered by this request:
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GENERAL FEES Outdoor Lighting Standard $1
SERVICES / POWER SUPPLIES Traffic Signal Standard $5
0 to 400 Amoere aC� S25 SIIf1f1IP.TP.O}AI FPP n PRiO
)MMUNICATION, REMOTE CONTROI
CIRCUITS OF LESS THAN 50 VOLTS
ivstem Device or Aooaratus al� 5.50
MULTIFAMIC
3to121
al Unit @ $25
OTHER ADDITIONAL FEES
fit @ $.25 per Fixture
rigatlon Boom @ $40
Home Park Lots Co� $25
Transformers over 10 KVA $ 20
Transformer / Power Su I for S ns / Outline Li htin $5
ONE 8 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 Ins ion Tri s $20
Investi ative Fee
Reins 'on Fee $20
TOTAL PEE O /1
(minimum total fee is $20) ��
THIS NREA FOR INSPECTOR USE ONLY
I hereby certdy that I inspected Me electrical installaGon described herein on the dates stated:
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5 ecial Inspection @$30 r Hour EXPIREDI�fl4NDOHED
S ial Inspection $.37 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITF
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ug pection Required? ❑ Yes o Inspection Other Than Rough-In: �teady Now � Will Call
����-' Q�C You must call the inspector when ready! Date Ready:
I certify that I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work ah
Job Site Street Address C�,
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Township Section Range Fire No. County
Owner/Occupant Name Please Provide Two (2) P�umbers Induding Area Code
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Electrical Utility Electrical Utility Address
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ailing Address (Contractor, Company or Ownf
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Authorized Signature (ConVador or Owper Pe
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License Number
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Please Provide Two (2) Phone Numbers
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