P - 78143REQUEST FOR ELECTRICAL INSPECTION
1��� 7��� 2 8 � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electriciry.state.mn.us
❑ NEW MODEL 0 ADDITION D REPAIR Describe -using the back of the white copy 'rf necessary - the work covered by this request:
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GENERAL FEES Outdoor Liahtina Standard l� 81
SERVICES
� Above 200 Ampere @$10
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus Cd $.50
fIFAMILY DV
3 to 12 Units
Rehofit
i @ S30 per Hour
i � 5.31 per Mile
�TION MAY I
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15795289
� Transfortners up to 10 KVA (d $10
� Transfortners over 10 KVA (D $ 20
Transformer / Power Supply for Signs / Outline Lightinq $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dqrelling Unit @$80
Fee
Fee
(minimum total fee is $20) 7�%
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I heieby ceAify that I inspecled the electrical installa6on described herein on the dates sta0ed:
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Request Dale: Rough-in Inspection Required? Yes ❑ No Inspection Other Than Rough-In: ❑Ready Now ❑ Wfll Call
5�' �� You must call the inspector when ready! Date Ready:
I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Address (Street, Box. or Route No.) Ciry ZiP Code
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Owner/Occupant Name Please Provide Two (2) Phone Nkimb�(s) I�luding /4ea Code
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Power Supplier Power Supplier Address
Con /� CompanK Name � Contracta License Number Master EleCtrician or Power Limited Technician
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