P - 760651��� O o� � REQUEST FOR ELECTRICAL INSPECTION
_ _ � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-500-627-3529 www.electt�icity.state.mn.us
Describe -using the 6ack of the whfte copy'rf ne .(�essa�v.=ihe �rork �gredby 3ki��t; S�I� I f C ii
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GENERAL FEES Outdoor Li htlng Standard @$1
SERVICES':POWER SUPPLIES Traffic Signal Standard @$5
0 to A00 Am re @$25 Su plemental Fee @$20
401 to 800 Am $50 Transformers u to 10 KVA $10
AbOVe BQO Am re@$75 Transfortners over 10 KVA @$ 20
CIRG�I�TS / FEEDERS Transformer / Power Su I for S' ns I OuUine Li h8n $5
0 to 200 Am re $5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes the Service and/or Power Supply up to 500 Amperes, All
ALARM, COhAMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dweliing Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS addt���Ai i����n�� T��a n a�n
TO THE
Boom
TOTAL FEE
total fee is $201
I hsreby ceitify that I inspected the electrical insiallation described herein on the dat� s�ted:
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115 tNSTALLATION MAY BE ORDERED DISCONNECTED_IF NOT COMPLETED WITHIN 12 MONTHS __ �
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�e' Rough-in Inspection Required7 ❑Ye �] No Inspection OtherThan Rough-In: �2eady Now ❑Will Call
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You must call the inspector when ready! Date Ready:
I c�rtify t�at I am the C�] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
MSTRUCYIONS ON BACK OF YELLOW COPY BOARD OF ELECTRICITV COPV ca_nm�m e_�c a� onnn