P - 81644REQUEST FOR ELECTRICAL INSPECTION
/� s } Minnesota Board of Electricity ° �
1- .�?-5 8�`t �� �: 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104
;A, .� (651) 642-0800 TTY/MRS 1-800-627-3529
' � www.electricity.state.mn.us �} '
IdentiTy the work covered by this request:
❑NEW ❑REMODEL ❑ADDITION ❑REPAIR ✓✓ v w � �Q� � �C (,C
GENERAL FEES tdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES 7raffic Si nal Standard �$5
0 to 400 Am ere C� $25 Su lemental Fee (� $20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10
Above 800 Am ere (� $75 Transformers ovei 10 KVA �$20
C CUITS ! FEEDERS Transformer / Power Su I for Si ns / Outline Li htin �$5
0 to 200 Am ere �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
A ve 200 Am ere �$10 Includes the Service and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Unit �$SO
ClRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Tri s�$20
Each S stem Device or A ratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins tion Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units �$50 Per Unit (minimum total fee is $20)
EBCh Addftional UNt �$25 FOH ��SPE�rop �SE ON��
OTHER ADDITIONAL FEES
Li htin Retrofit �$.25 er FiMUre
Center Pivot Irri ation Boom �$40
Manufactured Home Park Lots �$25 I trere certify mat I inspected the eledrical installaeon described herein on the dates smted:
Recreational Vehicle Park Sites �$5 t01GN "' °ATE
S te Bondin Ins ion �$20
S ial In ion �$30 r Hour "'"` "�tON DA7E
S ial In ion �$.31 r Mile Z—�'Z—
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF N COMPLETED WITHIN 8 MONTHS
FOR OFFICE USE ONLY
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Request at : Rough-in Inspectlon Required? ❑ Yes Inspection Other Than Rough-In: dy Now ❑ Will Call �
You must call the inspeclor when readyl Date Ready:
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, B, r Route No City �' T��
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Section Township Range Fire No. Counry
Occupant Phone D
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Power Supplier le�ldress
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Electri tractor / Company Name Contractor License Number Master License Number
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Mailing A ress (CoMr r, Company or ner PertormMg Installatlon)
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Authorized ign re C a or, Company or Owner Perfo ing Installation) P one
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EB-OOOOtA•13 7/1/2000 � . BOAHD OF ELECTRICRY COPY INSTFiUCilONB ON BACK OF YEILOW COPY