P - 79603",. _
REQUEST FOR ELECTRICAL INSPECTION
e� s Minnesota Board of Electricity �° �
,� - z 16 �� 1 H °`� p 1821 Universiiy 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�S �( t� ��,
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NEW ❑REMODEL ❑ADDITION ❑REPAIR � r,(j ` °L,.
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Tra�c Si nal Standard �$5
0 to 400 Am re �$25 Su lemental Fee �$20
401 to 800 Am ere �$50 Transformers u to 10 KVA (� $10
Above 800 Am ere �$75 Transformers over 10 KVA (� $20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns I Outline Li htin �$5
0 to 200 Am ere �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service andlor Power Suppty up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Tri s�$20
Each S stem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Aeins ' Fee (� $20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units �$5o Per Unit (minimum total fee is $20) ,5
Each Additionai Unit �$25 FOfl INSPECTOP USE ONLY
OTHER ADDITIONAL FEES
Li htin Retrofit �$25 er Fi�ure
Center Pivot Irri ation Boom �$40
ManufaCtUred Home Pal k LotS �$25 I hereby certify tl�at I inspecied ihe electrical instaila6on describ�i herein on the dates stated:
Recreatbnal Vehicle Park Sites �$5 "01G1'" 0A7E
Se rete Bondin Ins ection �$20
S ial Ins ection �$30 r Hour Fl""� "'�QfON °ATE
S ial Ins ection �$.31 er Mile �3�` �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
POR OFFICE USE ONLY
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Request Date: ��.-• Rough-in Inspection Required? ❑ Yes o Inspectlon Other Than Rough-In: Ready Now � WIII CaN
'� O You must call the inspector when ready! Date Ready:
I cerUiy that I am the [�.ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electricai work at:
Job Address (Street, Box, or Route No.) Ciry Zip Code
e $ -� er � � r� �e �r,'c� � ss s�,�Z
Section Township Ran e Fire No. Counry
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Occ�� � �� � � '� �� � Phone
Power Supplier Address
!S� �£� �5�`/1 w-�' ' �S /%1 �
Electrical Contrador / Company Name Contractor License Number M er ice Number
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Mailiny A�ess (Contrador, `ompany or Owner Performin� stallation) � + �����
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Autho ' d' natur ontract or Owner Performing Ins Ilatio ) Phone
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EB- A- 3 /1/2000 � BOARD OF ELECTRICITY COPY WSTRUCTIONS ON BACK OF YELLOW COPY