P - 773811 7 81 3 3 6 1 REQUEST FOR ELECTRI�'y4L INSPECTION
� � ❑ Minnesota Board of Electricity s�(QD.�-Ql �gS '*`
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 the back of the white copy if nee�e�� �he v�e� �e�a9tby �ki� �r�a�st: ��� ���� �_)
GENERALFEES
✓ICES I POWER SUPPLIES
0 to 400 Ampere (� $25
Above 200 Ampere @$10
2M, COMMUNICATION, REMOTE CONTROL, SIG
;UITS, CIRCUITS OF LESS THAN�50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
TIFAMILY DWELLINGS (PER UNIT)
3 l012 Units @$50 Per Unit
Each Additional Unit @ $25
Supplemental Fee $20
Transfortners up to 10 KVA @$10
Transfortners over 10 KVA $ 20
Transformer / Power Su I for Si ns / Outline Li tltin $5
ONE & 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
TOTALPEE
total fee is $20) Z��
Lighling Retrofit @$.25 per Fixture I hereby cedify that I inspected the electrical installation descnbed herein on the dales stated:
Cen(er Pivot Irrigation Boom @$40 R°"c"'"
Manufactured Home Park Lots @ $25
Recreational Vehicle Park Sites $5 F�Nn�iNSaecnoN
Se arate Bondin Inspection $20
Special Inspection @$30 per Heur exP�aeo�nenwoa+eo
Special Inspection @ $.31 per Mile
TNIS INSTALLATION MAY BE ORDERED DISCONNECTED IF IVOT CON
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D WITHIN 12 MONTHS
� ��� £-ti ��' �! i Rou h-in Ins ection Re uired?
g p q ❑ Yes �] No Inspection Other Than Rough-In: [�Ready Now � Will Call
� You must call !he inspector when ready! Date Ready:
I certify that I am the C� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
IJo�sl�t�g}reei'�e5� ( -�Ic� - ---- — -- - CityFitTiat.E.'�
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Section � Range � Fire No.
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Electrical Utility Electrical Utility Address
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�?�1�3�°(��`L'.�n?��:'�G � ��F:�'ll�{F17�t��N contractor�se���J rv�asterE�ectricianor
License Number
Mailing Address (Contractor, Company or Owner Performing Installation)
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Auy�prized �jy�atufe (Contractor or Owner Performing Installation) �lease�
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INSTRUCTIONS ON BACK OF YELLOW COPY BOARD OF ELECTRICITY COPY
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EB-00001A-15 8.7.2C