P - 79609REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity ' `�
�. � 111- 9 3 3 �$ �' 182� University Avenue Suite S-128, Saint Paul, Minnesota 55104
� � °a (651) 642-OS00 TTY/MRS 1-800-627-3529
www. e lectricity. state. mn. us
Identity the work covered by this request: 1
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR (� � J%� C� �
GENERAL FEES Outdoor Liahtina Standard �$1
0 to 400 Am ere �$
401 to 800 Am ere �
Above 800 Am re �
CIRCUITS ! FEEDERS
Above 200 Am ere � $10
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or ratus �$.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units �$50 Per Unit
Each Additional Unit � $25
OTHER ADDITIONAL FEES
Li htin Retrofit �$25 r Fixture
Center Pivot Irri ation Boom �$40 .
Manufactured Home Park Lots �
Recreational Vehicle Park Sites � , l
Su lemental Fee � $20
Transformers up to 10 KVA �$10
Transformers over 10 KVA � $20
Transformer / Power Su I for Si ns / Outline li htin �$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Inciudes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellin Unit �$8L
Additional Insoection Trios � $20
fee is
ir�stallation described herein an tlie dates ststed: . I
� � Special Inspection �$.31 per Mile � � �J – —/ "`–' �"
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLE'TED WITI�IN 18 MONTHS
FOR OFFICE USE ON�Y
� � �I�f I�il �1 + (! !i �
� � �1 ��� ��I� ����� ����� ����I1�If/ �1 � ���I ,
����jg��6* �e��� a�,�
Reaue atei� in � Rouah-in Insoection Reauired? fl Yes Insoection Other Than Rouah-In: Readv Now f�l Will Call
� �� � V� v- � You must call the inspectw when readyl � Date Ready: �
I certify that I am th�tiCENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job A (S eet, Box, or e No.) Ciry Zip
�� ��/� ��°��i.�1%� d� 1����0�' ���,�
���,t �z� �I a �-c �
Power Supplier Adc
Electrical Contrador / Company Name
Mailin� y � 8
Authorized Sign a���, �npa�opGr�ner F
t �� a7�+G�7
� (763) 5.i�-200U
EB-00001A43 7flYL000 �...
..w- .
ELECRi1CITY COPY
�z�3;
Master License Number
Il�TRUCTIONS ON BACK OF YELLOW COPY