P - 763681(� REQUEST FOR ELECTRICAL INSPECTION �
� 1� v��" � 4 6 5� Minnesota Board of Electricity �`/ �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 • s�
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoor Li htin Standard @$1
SfRViCES I POWER SUPPLIES . /' Traffic Si nal Standard a$5
0 to 400
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus an $.50
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighting Retrofit @ $.25 per Fi�Rure
Center Pivot irriaation Boom (a� $40
Sup lemental Fee $20
Transformers u to 10 KVA a$10
Transformers over 10 KVA $ 20
Transformer / Power Su I for S' ns / Outline Li htin $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
Additional Inspection Trips @ $20
� Investigative Fee
Reinspection Fee (�a $20
TOTAL FEE 5-Q
total fee is $20) � � *--°"'�"
I inspected fhe electrical installation desaibed herein on ihe dates slated: �
Se rate Bondi Ins ion $20 ,t�^_ -� '�'%
Speciallnspection $3� fHOUf ExaiqEOraanNOauE pA�
S ial Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rou h-in Ins ction Re uired? ❑ Yes ❑ No Ins
9 Pe q pection Other Than Rough-In: ❑ Ready Now f� Wil� Call
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�" ;��rj �-- � You must call the inspector when ready! Date Ready:
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY OWNER and hereby request inspection of the electrical work at
Job Site Street Address City
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Township Section Range Fire No. County
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Owner/Occupant Name Please Provide Two (2) Phone Numbers tncluding Area Code
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ON BAC OF YELLOW COPY
License Number I Master Electrician or Power Limited Technician )
License Number �
waaon� Please Provide Two (2) Phone Numbers InGuding Area Code I
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BOARD OF ELECTRICITY COPV FR�ufnnta_t5 a t �me