P - 81769REQUEST FOR ELECTRICAL INSPECTION
� Minnesota Board of Electricity
� 1-375-735 � 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: w� �� j, �, �� ��
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR — �1 G l,J IC,
GENERAL FEES Outdoor Li htin Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
� 0 to 400 Am ere �$25 a Su lemental Fee �$20
401 to 800 Am ere �$50 Transfortners u to 10 KVA �$10
Above 800 Am ere �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformers / Power Su I for Si ns / Outline Li htin �$5
j 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 Trips �$20
Each S stem Device or A aratus �$,50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reinspection Fee �$20
MULTIFAMILY DWELLINGS (PER UNI� ��� i� TOTAL FEE 3�,5(�
3 to 12 Units �$50 Per Unit (minimum total fee is $20) f
EaCh Additional Unit � $25 wr+insa�cTOnusEaa�v
OTHER ADDITIONAL FEES
Li htin Retrofit �$25 r Flxture
Center Pivot Irti ation Boom �$40
Manufactured Home Park Lots �$25 i nereny cenny n,ac i ��s�ea me eiec���i ��s�a�iaian desc�nad narein on me eeces �a�ea:
Recreational Vehicle Park Sites � ROUGH IN OATE
Separate Bondin Ins ction � $2
S ecial Ins ection �$30 per Hour Flru� wsvECrror, /��
S ecial Ins ection l� $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY
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'` 1 3757356'` ���
Request Date: Rough-in Inspection Required? ❑ Yes Inspection Other Than Rough-in: ady Now ❑�II Call
� You must call the inspector when ready! Date Ready:
I certi(y that I am the �ICENSED CONTRACTOR ❑ COMPAMY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Roule No.) City Z�P �e
� ��
Section Township Range Fire No. Coun
Occupant . Phone
`��3-3a-�- � �
Power Supplier � � c�r@s$�
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Electrical ontractor / Company Name Contrador license Number Master License Number
' C, a-3
Mailing Address (Contractor, Company or Owner Performing Installation) �
y y �. s 1
AutFwrize natur ont or n P n Ins Pho e
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1A-13 BOARD OF ELECTRICITY COPY INSTRUCTIONS ON BACK OF YELLOW COPY