P - 80127-
REQUEST FOR ELECTRICAL INSPECTION
1� w�� ��� v�° Minnesota Board of Electricity
� L � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529
' www.electricity.state.mn.us
Identity the work covered by this request: r�yO �G � 4 5'�� �
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❑ NEW �REMODEL ❑ ADDITION ❑ REPAIR
GENERAL FEES Outdoor Liahtina Standard @$1
VICES / POWER SUP
0 to 400 Ampere (� $;
401 to 800 Ampere �
A6ave 8�� Amoere �
Above 2� Am ere � $10
ALARM, COMMUNICATION, REMOTE CO
CIRCUITS, CIRCUITS Of LESS THAN 50
Each Svstem Device or Aaoaratus �
Transformers up to 10 KVA �
Trar�sformers rner 16 KVA �
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellin UnH �$8(
Addidonal Inspection Trips � $20
Investlaative Fee
3 ro �2 Units �$5o Per Unit (minimum total fee is $20) ��'
Each Additional Unit � $25 fOfl1NSPC�TOA "� °NLY
OTHER ADDITIONAL FEES � ��Q
Li hNn Retrofit �$.25 r Fixlure
Center Pivot Irri ation Boom � �jrQ��
Manufactured Home Park Lots � I hereby certi(y that I inspected the eleclriral installation described herein an ihe dates slated:
Recreational Vehicle Park Srtes �$5 fl01�"'" �i� ,_ DA7E
Se tate Bondi Ins � $20 �'""'"�—''
S ecial Ins ection �$30 er Hour FlNAL INSPECTION , M�
S ial Ins ecTion f� $,31 r Mile ��n
THIS INSTALLATION MAY BE ORDERED DISCONNECTED OT COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY
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R uest Date: Rough-in Inspection liequired? Yes ❑ No Inspection Other Than Rough-In: ❑ Ready (�iow � Wfll Call
���—�/ Z You must call the inspedor when readyl Date Ready:
I certify that I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical wodc at:
Job Address (Street, Box, or Rou[� o.) Ciry Zip Code
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Section Township Range ire No. Coun
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Power Supplier
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EI rical Contractor / Company Name CoMractor License Number M�ster License Number
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M� g Add� (Conhactor, �pany or Owner Perf
Authorized�gnat`re ontrac0 Company or Owner
Phone
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BOMD OF ELECTRICITY COPY N13TNUC710N8 ON BACK OP YELLOW COPY