P - 79783REC�UEST FOR ELECTRICAL INSPECTION
1 2 0 5 4 5 0 Minnesota Board of Electricity ��
� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
m (651) 642-0800 TTY/MRS 1-800-627-3529
www.electricity.state.mn.us �' �
Identify the work covered by this request:
W ❑ REMODEL ❑ ADDITION ❑ REPAIR � ' : �
GENERAL FEES Outdoor Li htin Standard �$t
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am ere �$50 Transfortners u to 10 KVA �$10
Above S00 Am ere (� $75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns I Outline Li htin �$5
0 to 200 Am ere �$5 " C ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere �$10 Includes the Service and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips E2ch Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additlonal Ins ection Tri s�$20
Each S tem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ection Fee �$�
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to i2 Units �$5o Per Unit (minimum total fee is $20) d
E2Ch Additi0nal Uflit �$25 wn iNSaecroR use a+�v
OTHER ADDITIONAL FEES
Li htin RetroM �$25 r Fixlure
Center Pivot Irti ation Boom �$40
ManufaCtured Home PaPk Lots � I hereby ceNty that I inspected 1he electrical installatian described herein on the detes stated:
nou�� m on�
Recreational Vehicle Park Sites �
Se rate Bondin In 'on � $20
w� x�aw . � o��
S ial Ins �on �$30 er Hour �,�\ J2� �
S ecial Ins ection �$.31 er Mile
_-rW�c INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
Foe oF� usE oN�r
� l���il �ii�� �1��� �I��i �1���'I�I� ����1 � ��^
IiiIIlNllll `�/�,
�E 1 2 O 5 4 S Q B 3E [', ('�1 1—C ,��<<�
� t J���,� I You must call the inspector when ready� \ I Date Read � I` I
Y
I certify that I am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Fioute No.) Cil� , �� Zip Code
� r, 1�._ n � '\ A � �
Fire
Occupant ' � � � � �
S�r I � 3 0 0 4 2 Ph°ne
Power Supplie q��� �
al Contractor / Company Name CoMractor License Number Master License Number
rwa,S�e. � l�,c. wc, G A�o
Address (Contractor, Company or Owner Pertortning Installation)
° ` ` SS3�
� �
�ed Signature (C tractor, Company or Owner erfo mg Installation) Phone
r -'2 v- Z`ilc, 951— �f 3—oZ�S�.
�-13 7/1/200p BpARD OF ELECTp�CRy Cppy INS7AUC710N3 ON BAC OF YELLOW COPY