P - 77104REQUEST FOR ELECTRICAL INSPECTION ��'�'�
1— 910 — 0 4 5 0 Minnesota Board of Electricity � �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 551 Q& �
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us ,
Describe -usin he back of the white opy if necessary - the wo covered by this req st:
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GENERAL FEES Outdoor Li hting Standard @$1
SERVICES I POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Amcere (a� $25 Suoolemental Fee an $20
I ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
� CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Apparatus a� $.50
Each Additional Unit @
Lighting Retrofit @ $.25 per Fi�ure
Center Pivot trrigation Boom @ $4(
Manufactured Home Park Lots an $
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 cGon Tri $20
Investi ative Fee
Reins ection Fee $20
TOTAL FE
(minimum total fee is $20
THISAREAFORINSPECTORUSEONLY .�_D �
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I hereby certify ihat I inspeded the electriral installation described herein on the dales stated:
.-:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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�uace: Rough-in Inspection Required? ❑ Yes �Jo Inspection Other Than Rough-In�eady Now ❑Will Cail
( � Q�� '�% � You must call the inspector when ready! Date Ready:
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job SRe Streef Address
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