P - 78277REQUEST FOR ELECTRICAL INSPECTION
1 2 91 4 4 8 Minnesota Board of Electricity
� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 =
www.electricity.state.mn.us
Identify the work covered by this request: ^--.��// ��� �M� ��v/��
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR �
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Tra(fic Si nal Standard �$5 t,,l.
0 to 400 Am ere �$25 !� Su lemental Fee �$20
401 to 800 Am re �$50 Transfortners u to 10 KVA �$10
Above 800 Am ere �$75 Transformers over 10 KVA �$20
CIRCUITS I FEEDEAS Transfortner / Power Su for Si ns / Outline Li htin �$5
0 to 200 Am re �$5 NE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service andlor Power Supply up to 500 Amperes, AII
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dweilin Unif �$SO
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additlonal In ion Tri �$20
Each S stem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reinsoection Fee �$20
3 to 12 Units �$50 Per Unit
Each Additional UnR � $25
OTHER ADDITIONAL FEES
Lighting Retrofit � $25 per Fixture
Center Pivot Irrigation Boom � $40
Manufactured Home Park Lots � $25 �
Recreational Vehicle Park Sftes � S5 n
Hour
1
� � Special Inspection �$.31 per Mile � �
THIS INSTALLATION MAY BE ORDERED DISCONNECTE
FOR OFFICE USE ONLY
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total fee is
i inspecled the electrical installafion described herein on the dates
_ � �` c-/ �T I
.ETED WITHIN 18 MONTHS
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I certity that I am the� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Route No.) _ City _ � Zp Code
Power Su plier
Electri �ontractor / Company Name �
Mailing� ress (Contrado� mpan or Own
/
Authorized Si re (Contrador, Company or
�� r
�t
No.
3� f; � 3 I Phone
Address
Contractor License Number
:, _ l„�90��/,
Master License Number
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BOARD OF ELECTRICITY COPY INSTRUCTIONS ON BACK OF YELLOW COPY