P - 77476REQUEST FOR ELECTRICAL INSPECTION
1� I V 1- 9 31 3 Minnesota Board of Electricity ""�. `_
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 ,�:
(651) 642-0800 TTY/MRS 1-800-627-3529 ti��ww.electrrcitv.state.mn.:�s
Describe -using the back of the white copy if ne �,s ...: the yyD, e,�I byl�i 4u t;
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GENERAL FEES Outdoor Lighting Standard @$1
SERVICES / POWER SUPPLIES Traffic Signal Standard @$5
Above 800
Above 200 Ampere @$10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
MUL7IFAMILY DWELLINGS PER UNIT
3 to 12 Units �$50 Per Unit
ADDITIONAL
Pivoi Irrigation Boom @ $4C
ctured Home Park Lots @ g
lional Vehicle Park Sites @
Ie Bonding Inspection @ $2
Insoection la� $30 oer Hour
Supplemental Fee @ $20
Transformers u to 10 KVA $10
Transformers over 10 KVA a$ 20
Transformer I Power Su I for Si ns I Outline Li htin $5
ONE 8 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
Investipafive Fee
TOTAL FEE I '?il '�� "
,._ . � ,+��
(minimum total fee is $20)
ihat I inspected the electrical installation described herein on the dates stated:
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Special Inspection @ $.31 per Mile
TFiiS INSTALIATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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��,�Date: - � ��i Rough-in Inspection Required? ❑ Yes �� No I, Inspection Other Than Rough-In: [�Ready Now ❑Will Call
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��� i You must call the inspector when ready! II Date Ready:
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f cerUfy thai I am the �] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
j Job Site9 S�street Address —7--�`� y� ------ -- —�tY ;- it .� �� i_ �T j i h; !-, � iA �; �
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, Townsh�p I Section !I Range 'I Fire No. I County
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.��, Owner/Occupanl Name I Please Provide Two (2) Phone Numbers Including Area Code
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' Elactrjcal Utili�ty I Electncal Utility Address
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rCpntractOr / Company Name �� Contractor License Number I Master Electrician or Power Limited Technic
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Ma�ling Addres& (Contractor, Company or Owner Performing Installation)
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�, Aut�prized S' nature Contractor or Owner Performin Installation Please Prowde Two (2) Phone Numbers Including Area Code
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