P - 76567REQUEST FOR ELECTRICAL INSPECTION �
1����- 9 0 6 1 Minnesota Board of Electricity ;r .�'
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 - -
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.s/ale.mn.us
Describe -using the back of ihe white copy if ne�s���the �vArkFqye[�d.by�i� ����,sh,
i- �r�tr`�,'� ra M � SW:lTCN
0 to 400 Ar
401 to 800
Above 800
CIRCUITS I FEE
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparalus @$.50
ADDITIONS TO THE GENERAL F
MULTfFAMILY DWELLINGS (PER UNIT)
3 to 12 Units @�50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irriqation Boom (cil $4C
oumoor
Supplemental Fee @ $20
Transformers up to 10 KVA @$10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns I Outline Li htin $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
Additionai Inspection Trips @ $20
Investiqative Fee
TOTALFEE �(}e
(minimum total fee is $20)
that I inspected the electrical installation described herein on the dates stated:
Se arate Bondin Ins ection $20 —�'---�—� �"� � D`�
Special Inspection @$30 per Hour =xPP`� aBa^^o�E� o�,.E
S cial Inspection @$.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS _
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� '�, Rough-in Inspection Required? ❑ Yes �] No �'� Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
I 1!�'�fr7�y
'�.`_ ! You must call the inspector when ready! '� Date Ready:
I certify that I am the L�l LICENSED CONTRACTOR O COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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Owner/Occupant Name I Please Provide Two (2) Phone Ni
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�i Electrical Utility � Electrical Utility Address
�XGEL Etll �+�Y ��
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�� Contractor / Company Name ; Contractor License Number 'I Master Electrician or Power Limited
I HU1�iT ��._El`;7R7C 'I:tJFil='C1Rf17:Ct7P? ' Gft C1G�iSa I��oe�serv�mber
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: Mailing Address (Contractor, Company or Owner Performing Installationj
I �,�4� 1"l::Ri�;ITCIhIAL �i(]Ai�g :�riIh�}T �'�1f.1L„ f�l�i .`_'�5�.�.�
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� Authorized Signature (Contractor or Owner Performing Installation) � Please Provide Two (2) Phone Ni
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INSTRUCTIOHS ON BACK OF YELLOW COPY � BOARD OF ELECTRICITY COPV
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; Including Area Code
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