P - 81909REQUEST FOR ELECTRICAL iNSPECTION
�. 1 Q� O 6 H e Minnesota Board of Electricity �"'
� � ��
� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTYIMRS 1-800-627-3529
www. e lectriei ty. state. mn. us
IdentiTy the work covered by this request:
❑NEW EMODEL ❑ADDiTION ❑REPAIR b C � lJ1�Jj � y- �'��OC��
GENEA,4L FEES Outdoor Li htin Standard �$1
SERViCES i POWER SUPPLiES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am ere �$50 Transformers u to 10 KVA �$10
Above 800 Am ere �$75 Transformers over 10 KVA �$20
IRCUITS J FEEDERS Transformer / Power Su I for Si ns / Outline Li htin �$5
0 to 200 Am re �$5 ONE & 7W0 FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service andior Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Unit �$80
ClRCU1TS, CtRCUITS OF IESS THAN 50 VOLTS Additionai �ns ection 7ri s�$20
Each S stem Device or A ratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins 'on Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE �
3 to 12 Units �$50 Per Unft {minimum total fee is $20)
Eech Additi0flal Unit �$25 �a' i"5"EC�°" �'� °rn�
OTHER ADDITIONAL FEES
Li htin Retrofit �$25 er Fixture
Cenier Pivot Irri ation Boom �$40
Manufactured Home Park Lots �$25 I hereby ce ' thaf I inspected the electrical insm�latlon descrihed herein an u�e datas stated:
Recreational Vehicle Park Sites �$5 fl01G1'" °"'�
Se arate Bondin Ins 'on � $20
S ecial Ins ection �$30 r Hour "'"""�8"0N '% DA7E
S ecial Ins ection �$.31 r Mile '� � /`�'�� �� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY
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�. Request Date: Rough-in Insp�tion Required? ❑ Yes o Inspectlon Other Than Rough-In: ❑ Ready �"--
� ��� You must call ihe inspector when ready! Date Ready:
I certi(y that � am LICENSED COPITRACTOR ❑ CONiPANY ❑ OWNER and hereby request inspection of ihe electrical work at:
,bb Address (Street, Box, or Route No.) Ciry Zp Code
(�s50 �i c% l SE. �sl Ci I �S�/�
Section Township Ranga Fire No. Co
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pacu I � r Phona � ' �� � — �I � Y' p�
T((I
Power SuppUer Address
Electrical Co Contrador License Number Master License Number
1�.562 EI� RAL �l�J�. i�.F_.
�a�� ����,�. l�m�l�sss
Mailing Address (Contractor, Company or Owner PeAorming Installation)
Authorized Sig re ontrador, omp ny er ormin lation) Phone
' • �� � � r ��O
EB�UU�O1A-13 , BOAHD OF ELECTAiCRY COPY INS7AUCilONB ON BACK OF YELLOW COPY