P - 79509. REQUEST FOR ELECTRICAL INSPECTION
1 2 8 7 5 7 7 vq � Minnesota Board of Electricity —
� � 1821 University :�venue Suite S-128, Saint P ul, Minnesota 55104
` �°°°� (651) 642-OS00 TTY/MRS 1-800-627-35 ' �
www.electricity.state.mn.us �x'
Identify the work covered b this re esY
y qu .
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR (,/C/ �L/`-' � ( C .
GENERAL FEES Outdoor Liqhtinq Standard �$1
SERVICES / POWER SUPPLIES
0 to 400 Am ere (� $25
401 to S00 Am ere �$50
Above 800 Am ere � $75
CIRCUITS / FEEDERS
0 to 200 Am ere �$5
Above 200 Am ere � $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aratus f� $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units �$50 Per Unit
Each Additlonal Unit � $25
OTHER ADDITIONAL FEES
� htin Retrofit � $25 r Fixture
Center Pivot Irri ation Boom �$40
Manufactured Home Park Lots � $2
Recreational Vehide Park Sftes � $5
Traffic Siqnal Standard � $5
Su lementa4 Fee � $20
Transformers u to 10 KVA �$10
Transformers over 10 KVA � $20
Transformer / Power Su I for Si ns / Outline Li htin �$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Suppty up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellinq Unit �$8(
Fee �
UN INSPECTOP USE ONLV
F(h/- �r -/7 ^o t
I herebvi certify that I inspected the
� I Special Inspection �$.31 per Mile � � L /
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMP
FOR OFFICE USE ONLY
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Requ a. Rough-in Inspection Required? ❑ Yes Inspection OMier Than
You must call the inspector when ready. Date Ready: l(
I certify that I am �cENSED CONTRACTOR ❑ COMPANY ❑ OWNER r and hereby
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Job Addre���ox, or Rou�o.) . �^� Ciry ¢--^ /,
No.
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Electrical Co or / Company Name �^ � Contractor License Number
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Mailing Add (Contract r, Company or ner Performing Installati n)
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Authorized Signature ( ontractor, Co y or Qwner Perto ' g Installatlon) Phon�
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EB-OOOOtA43 7/1/2000 BOARD OF ELECTHICITY COPY
total fee is
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WITHIN 18 MONTHS
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inspection of the electrical work at:
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INSTFiUCTONS ON BACK OF YELLOW COPV