P - 77317REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electriciry '�•
1� 3 4 7- 4 81 �82� University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529
www.electricity.state.mn. us
Identify the work covered by this re t:
❑ NEW p REMODEL DDITION ❑ REPAIR
0 to 400 Am ere �$25
401 to 800 Am ere �$50
Above 800 Am ere � $75
CIRCUITS / FEEDERS
0 to 200 Am re�$5
200 Am re � $10
LARM, OMMUNICATION, REMOTE CONTROL,
S, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus �$.50
3 to 12 Units �$50 Per Unit
Each Additional Unit � $25
OTHER ADDITIONAL FEES
Lighting Retrofit � $.25 per Fixture
Center Pivot Irrigation Boom � $40
Manufactured Home Park Lots � $25
Recreational Vehicle Park Sites � $5
Separate Bonding Inspection � $20
Special Inspeclion � $30 per Hour
Soecial Insoectlon � 5.31 cer Mile
Traific Si nal Standaro � $5
Su lemental Fee � $20
Transfortners u to 10 KVA �$10
Transformers over 10 KVA � $20
Transfortner / Power Su for Si ns / OuUine Li htin �$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Suppty up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellin Unit �$BC
AddiGonal Inspeclion Trips � $20
Investlaative Fee
that I insoected tlre electrical insqlla6on
FOR OFFICE USE ONLY
ilNilllllllilllllllil{IIIIIIIIIllllllllllllllllll � a��
�E 1 3 4 7 4 8 3 C�E
total fee is $20) � —
/��
. 5a �'c.�,
iG ( -�7��
OMPLETED WITHIN 18 MONTHS
_ �o �.�a
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Route No.) Ciry 2ip Code
5 700 � f��'v�2 �.1� . �2't v��� S�'S�3?-G�Y
Section Township Range Fire No. Counry
J4 n�o �S,Q .
Occu �t{� ` � ��� ` l.: � Phone � � � / / ^ ��
7 eX
Power Supplier Address
Electrical Contract r/ Company Name Contractor License Number Master License Number
7 �, ?Soi � a3
Mailing Address (Contractor, Company or Owner Perfortning Installation)
n .�lc� C't .
orized S nature t�ractoJ Co y or Owner Performing Installation) Phone
r QCI� �Q./,sZ — ,j' C�� ! y���
E&OOOOIA-13 7/1/2000 BOApD OF ELECTRICITY COPY MISTNUC710NS ON BACK OF YELLOW COPY