P - 76482REQUEST FOR ELECTRICAL INSPECTION
1�( O�- 9 2 6 3 Minnesota Board of Electricity ;��'.
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back o?tl� white copy if nece�s the yeqr�,cqu�r�. byth��e �,sh
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GENERAL FEES Outdoor Lighting Standard @$1
SERVICES I POWER SUPPUES Traffic Signal Standard $5
0 to A00 Ampere $25 Supplemental Fee @$20
401 to 800 Am ere $50 Transformers u to 10 KVA $10
Above 800 Ampere (� $75 Transformers over 10 KVA (cil $ 20
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0 to 200 Am ere $5 �
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
FEES
I Home Park Lots
Vehicle Park Site�
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ection Tn s $20
Investigative Fee
Reinspection Fee $20
TOTAL FEE s !;,
total fee is
I hereby certify ihat I inspected the electrical installation descnbed herein on ihe dates slated�
rate 8andi Ins ction $20 �---��1Q-�--+�-- -�' a%
SpBCi2l Insp2C1i0n $30 p2f HOUf ExaiaEO neaNOOr+EO onre
S ial Inspection @$.31 per Mile
TH1S IMSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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�, uaie: �; Rou h-in Ins ection Re uired? ❑Yes
. j_, r�' ,r L g p q No ��, Inspection Other Than Rough-In: [�Ready Now � Will Call
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I certity that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
�Job Site Sit Address _- _ _ _ _- __ - _ -- — _— Cit ' i:
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�i Owner�lO�GCUpan3t Name
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Range i Fire No.
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Area Code
j EleCtric�l IJ61iy � Electrical Utility Address
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� Contractor / Compan� Name � L Conlractor License Number Master Electrician or Power Limited Techni�
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Mading Addrgss Contractor Com�pany or Owner Performin Installationl
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nzed 3� nature (Contractor or Owner Performing Installation) Please Provide Two (2) Phone Numbers Including Area Code
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