P - 76609REQUEST FOR ELECTRICAL INSPECTION �'�
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2� O 2�� 7�23 �` Minnesota Board of Electricity �� �
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �'
�l (651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
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Describe -using the back of the white copy if necessary - the work covered b this request:
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ENERAL FEES Outdoor Lightin Standard $1
SERVICES I POWER SUPPLIES Traffc Si nal Standard $5
0 to 400 Ampere $25 Supplemental Fee @$20
401 to 800 Am ere $50 Transformers u to 10 KVA $10
Above 800 Am re $75 Transfortners over 10 KVA $ 20
CIRCUITS I FEEDERS Transformer / Power Su I for Si ns I Outline Li htin $5
0 to 200 Am ere $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere $10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Inspection Tri s $20
Each S stem Device or Apparatus $.50 Investigative Fee
ADDITIONS TO THE GENERAL FEES Reins tion Fee $20
MULTIFAMILY DWELLINGS PER UNIT TOTAL FEE C�./�
3 to 12 Units @$50 Per Unit (minimum total fee is $20) �-v •��
EeCh Addlfi0nei Uf11f @ $25 THISAREAFORINSPECTORUSEONLY
OTHER ADDITIONAL FEES
L� hting Retrofit $.25 per Fixture I hereby certify that I inspected the electrical installation desaibed herein on ihe dates stated:
Center Pivot irri ation Boom $40 R01GH1N � o"TEq
Manufactured Home Park Lots $25 •!p 2` "�
Recreational Vehicle Park Sites $5 F�w�� �NSa�cT�or+ on,e
Se arate Bondin Ins ion $20 ��—�--- ����'�G
Special Ins ection @$30 per Hour EXPIRED�A94NpONED on�
Special Ins ion $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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�0257333 �!�;��;�-�'� �� �
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Date: Rough-in Inspection Required? Yes ❑ No Inspectian Other Than Rough-In: ❑ Ready Now ill Cail
cy� �� 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 SVeet Address �'
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Township Section Range Fire No. County
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OwnedOccupant Name Piease Provide Two (2 Phone Numbers Including Area Code
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Electrical Utility Electrical Utilily Address
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Contrad r/ Company Name ( Contractor Lice'nqse Number Master Electrician or Power Limited Technician
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Mailing Address (Contractor, Company or er Performing InstallaGon)
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A raed Signature (Contractor or Owner Perfortning InstallaGon) P ase Provide Two (2) Pho e Numbers Including Area Code
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INST CTIONS ON BACK OF V O PV ann nc Fi Fcraicirv cnov �o M,��,.. ,� o..,..,..