P - 77244REQUEST FOR ELECTRICAL INSPECTION ��
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� � ❑ Minnesota Board of Electricity �- �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �.
(651)642-0800TTY/MRS1-800-627-3529 www.electricity.state.mn.us !,�:�
Describe -using the back of the white copy if necessary - the work covered by t is request:
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GENERAL FEES Outdoor Li htin Standard $1
SERVICES / POWER SUPPLIES Traffic Signal Standard $5
0 to 400 Ampere $25 Supplemental Fee $20
401 to 800 Am ere $50 Transfortners u to 10 KVA $10
Above 800 Amcere Cd $75 Transfortners over 10 KVA (a� $ 20
llITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL I
fIFAMILY DWELLINGS (PER UNIT)
3 to 12 Units @$50 Per Unit
Each Additional Unit (a@ $25
Center Pivot Irrigation Boom �
Manufactured Home Park Lots
Special Ins ection a$30 per Hour
S ial Ins 'on $.31 per Mile
THIS INSTALLATION MAY BE ORDERED
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18L56356
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiaative Fee
total fee is $20) I �/D �
I herebv certiN that I inspeded the elechical installation described herein on ihe dates stated:
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Date: Rough-in Inspection Required? ❑ Yes ❑ No Inspection Other Than Rough-In: � Ready Now ill Call
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�` �� b � 8� You must call the inspector when ready! Date Ready:
I certify that I am thg�'�CENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address City
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Township Section Range Fire No. County
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Owner/Occupant Name Please Provide Two (2) P one Numbe ncluding Area Code
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Mading Address (Contractor, Company or
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Authorized Signature (Contrac or OHn
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Performing
Gontractor License Number Master Electncian or Power Llmitetl Techmc
C A O�Y � License Number�rna � 6 ys
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Please Provide Two (2) Phone Numbers Including Area Code
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