P - 77144RE(�UEST FOR ELECTRICAL IN ECT ON
Minnesota Board of Electricity (�(�'' ��99
1� 3 4 7- 5 2 3 1821 University Avenue Suite S-128, Saint aul, Minnesota 55104 �
(651) 642-0800 TTY/MRS 1-800-627-3529 - _
www. electricity. state. mn. us
IdeMity the work covered by this request:
❑ NEW ❑ REMODEL I�ADDITION ❑ REPAIR �} G`
GENERAL FEES Outdoor Liahtina Standard � S1 � 1_,o
0 to 400 Am ere �$25
401 to 800 Am re �$50
Above 800 Am re � $75
CIRCUITS / FEEDERS
0 to 200 Am re �$5
Above 200 Am re � $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or aratus �$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units �$50 Per Unit
Each Additbnal Unit � $25
OTHER ADDITIONAL FEES
Li htin Retrofd �$25 er Fixture
Center Pivot Irti ation Boom �$40
ManuFactured Home Park Lots � $25
Recreatlonal Vehide Park Sites � $5
Su lememal Fee � $20 (�/�
Transformers u to 10 KVA �$10
Transformers over 10 KVA � $20
Transformer I Power Su I for Si ns I Outlin i htin �$5
ONE & TWO FAMILY DWELLIN�S, EACH UNIT
Includes the Service andlor Power Suppty up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellin Unit �$S(
Additional Ins ection Tri s�$20
Investi ative Fee
Reinsoection Fee � S20
iv�n� r��
total fee is $20)
wn irsaECroa us� aav
� T.
I hereby cer6ty thal I inspected the electrical installation described herein an the dates slated:
nour.H rc� �� w� `L
� �-� w
�
S'al In ' n�$.31 r Mile Z� `
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 46 MONTHS
— �e.� —
FOR OFFICE USE ONLY
� ii���� t�i�i «r�� i��lt�ii�i� i���� �i�r1 ����� i«i �iii a�� �� ���
�E i 3�1 7 5 Z 3 1 �E �
Requ t ate: Rough-in Inspection Required? es ❑ No Inspection Other Than Rough-In: ❑ Ready Now Will Call
�/9 D� 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 Address (Street, Box, or Route No.) C' Zip Code
9 ` �-� dfe� S'��3L
�
I Elechical
� Mailing
,..,....,r �d
ae� � Y�.�
���
:tor / Company Name
Dc� �v�
fContraWen. Comoanv or Own
L�'k�,l��
Address � � �
% �J
er Per(orming Installation)
or Owner Performing Installation)
ounry
�,v� � �
P� b�-� I-8 I�
D��l7 �Il%/S/D.v
mse Number Master License Number
= �- � ;., �
�- Cs� (� - Fjl� ' i1 �
Phone
I I /la� ' � / / ` C><'�f I
EB-00001A-13 7/1l2000 BOARD OF ELECTRICITY COPY . INSTRUCTpN$ ON BACK OF YELLOW COPY