P - 78254`, REQUEST FOR ELECTRICAL INSPECTION
�°�F 5 6— 4 2 7 � Minnesota Board of ElecUicity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
0 NEW ' EMODEL ❑ ADDITION ❑vREPAIR Describe -using the b�k of the white copy 'rf necessary - the work covered by this request:
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GENERAL FEES Outdoor L' htin St�dard $t
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Amcere � E25 Suoolemental Fee � S20 _ 1 /� . _
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS Of LESS THAN 50 VOLTS
Ea�h S stem Device or atus $.50
ADDITIONS TO THE GENERAL I
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Per Unit
Each Addi6onal Unit @ $25
OTHER ADDITIONAL FEES
Li htin Retrofit $.25 er Fixture
Center Pivot Irti ation Boom $40
Manufactured Home Park Lots E25
Recreational Vehicle Park Sites $5
Se arate Bondin Ins tion E20
Special Insoection � $30 cer Fbur
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspec6on Trips Each Dwelling Unil @$80
TOTAL FEE I �
(minimum total fee is $20) � �•�v
rws �a�nFOn nsr�cTOn us� aar
I hereby ceAily that I inspecG2d the electrical installa6on described herein on the dates stated:
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Request Date: Rough-in Inspeclion Required? Yes ❑ No Inspedion Other Than Rough-In: ❑Ready Now II Call
'�y �Z: � You must calf the inspeclw when ready! Date Ready:
I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elechical xrork at:
Job e Address (Street, Box, or Route No.) City Zip Code
S g i'�s� ��n1 U� ��.�1 c.e $ 3�
SeUion Township Range Fire No. Caunty �
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Owner/OaupeM Name Please Provide Two (2) Phone Number(s) Induding Area Code
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ailing Address (Contractw. Campany or Owner Perfortnin
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ith SignaWre (Qbnt�dor� ComRd�Y a Ov�47 Perfc
OF YELLOW COPY
lier Address
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Contracta License Number Master Electridan or Power Limited Technician
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Installffiion) Phone (s)
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!D OF ELECTRICRV COPV E8-00001A-14 8.1. 2002