P - 76509REQUEST FOR ELECTRICAL INSPECTION �� �
I 1� 8 2��r 5 0 0 � Minnesota Board of Electricity �- �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 ��, `
(651) 642-0800 TTY/MRS 1-800-6273529 www.electricity.s�ate.mn.us .�gs�
Describe -using the back of the white copy if necessary - the work covered by this request: �� r� �
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GENERAL FEES Outdoor Lightin Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard @$5
0 to 400 Ampere @$25 Suoplemental Fee fa� $20
Above 200 Ampere a $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALIP
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Unfts @$50 Per UnR
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Li htin Retrofit $.25 per Fi�ure
Center Pivot Irri ation Boom $40
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites $5
Se arate Bondin Ins ion $20
S ial Inspection $30 per Hour
S cial Ins ion $.31 r Mile
THIS INSTALLATION MAY BE ORDERED I
I IIII II II II iii li i-i II III il III II III II III Ni� I��i
� Transformer I Power Supply for Signs I Outline Lighting @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional ins ection Tri s a$20
Investi ative Fee
Reins ection Fee a $20
TOTAL FEE �
(minimum total fee is $20) �
I hereby certi(y that I inspected ihe
RWGHIN
described herein on the dates stated:
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NOT COMPLETED WITHIN 72 MONTHS
1 8 2 0 5 � 0 5 2�d l0 - �� �� 3
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Date: Rou h-in Ins ection R
g p equired? es ❑ No Inspection Other Than Rough-In: ❑ Ready Now iil Call
(; � 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 ai
Job Site Street Address ��,
7(�y9 �r�iZ�v�c Q, �.��c�1�.�
Township Sedion Ranae Fire No. Countv
, r►s L� c��o�
31 UtllRy
3or / Company Name
Address (Contractor, Company or
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�zed re (Contr or or Owy
Installation)
Please Provide Two (2) Phone Numbers Incl
(�s�)Gy3-3»S ((��)y
License Number I Master Electrician or
License Number
Please Provide Two (2) Phone Numbers
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Technician I
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