P - 77139REQUEST FOR ELECTRICAL INSPECTION
1 3 4 7 4 5 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.electriciry.state.mn.us
Identify the work covered by this request:
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR �/U�+ _ `'t """ � , d.�' *L GCG � l
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am re �$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10
Above 800 Am re �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su for Si ns / Outline Li htin �$5
0 to 200 Am re �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service andlor Power Suppty up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwe�lin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOITS Additional Ins 'on Tri �$20
Each S stem Device or A ratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ion Fee (� $20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to �2 Units � E5o Per Unit (minimum total fee is $20)
EaCh Addltl0f�el Unit �$25 � INSPECTOH IISE ONLY
OTHER ADDITIONAL FEES
Li htin RetroM �$25 r Fature
Center Pivot Irri tbn Boom �$40
M2llufaCturOd Hal�e Pa�k LotS �$25 I hereby ceAily that I i ed the electrical installation desaibed herein on ihe dates siated:
Recreational Vehicle Park Sites �$5 101C�'" o�'�
S rate Bondi I ion (� $20 ��
S'al In ion �$30 r Hour F'"""'�`�10N � °��
S ial Ins ection �$.31 r Mile 1' ��'
THIS INSTALLATION MAY BE ORDERED DISCONNECTE COMPLETED ITHIN ��JNONTHS
FOR OFFlCE USE ONLY
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�E 1 3 4 7 4 5 O 7�
Request Date: Rough•in Inspection Required? ❑ Yes ❑ No Inspection Other Than Fough-In: ❑ Ready Now � Will Call
You must call the inspector when readyl Date Ready:
I ceRi(y that I am the ❑ LICENSED COhITRACTOR ❑ COMPANY �WNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Rou[e No.) Ciry � Zip Code
�S� � � Z-�-►� 5��'� �� .�`� 5� y 3 z
Section Township Range Fire No. County
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Occupant �� �� � ��� �� Phone �� _ �� � _��� �
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Power Supplier . Address
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Electrical Contractor / Company Name Contractor License Number Master License Number
Mailing Address (Contractor, Company or Owner Performing Installation)
Authoriz ture ( t or, C mpany or er Pe rtning Installation) Phone
EB-0W01A-13 7/1/2000 BOARD OF ELECTAICRY COPY INSTRUCT10N3 ON BACK OF YELIOW COPY