P - 77630REQUEST FOR ELECTRICAL INSPECTION
1 3 4 7 4 3 4 Minnesota Board of Electricity
� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 T'fY/MRS 1-800-627-3529 =
www. electricity. state. mn. us
Identify the work covered by this request:
❑NEW JrjREMODEL ❑ADDITION ❑REPAIR �L�vl�+�'t.,� lj/3,.C.c,« v�L'Z o
GENEFiAL FEES Outdoor Li hti� Standard �$1
SERVICES / POWER SUPPLIES Traific Si nal Standard �$5
0 to 400 Am re �$25 Su emental Fee �$20
401 to 800 Am ere �$50 Transformers u to 10 KVA �$10
Above 800 Am re �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li htin �$5
/ 0 to 200 Amcere � S5 ONE & TWO FAMILY DWELLINGS EACH UNIT
2W Ampere � $10
1MMUNICATION, REMOTE CONTROL,
CIRCUITS OF LESS THAN 50 VOLTS
ystem Device or Apparatus � $.50
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units �$50 Per Unit
Each AddiGonal Unft � $25
OTHER ADDITIONAL FEES
Li hG Retrofit �$.25 r Fixture
CeMer Pivot I' fion Boom �$40
Manufactured Home Park Lots � $25
Recreational Vehicle Park Sites � $5
Se rate Bondin In 'on � $20
S ial I ' �$30 r Hour
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellin Unft �$8(
Additional Inspection Trips � $20
Investiaative Fee
(minimum total fee is $20) � j
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ity that l inspected the e c[rical installabon described herein on the dates
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S ial Inspection �$.31 r Mile
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_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFRCE USE ONLY
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Request Date: Rough-in Inspection Required? ❑ Yes ❑ No Inspection OTher Than Rough-In: ❑ Ready Now ❑ Will Call
(� 9�� You must call Me inspector wF�en readyf Date Ready:
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY�[] OWNER and hereby request inspection of the electrical work at:
Job Address (SUeet, Box, or Route No.) City Zip Code
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Section Township Range Fire No. County
Occupant Phone
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Power Supplier Address
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Electrical Contrador / Company Name Contractor License Ni
Mailing Address (Contractor, Company or Owner Performing Installation)
or
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Master
Phone
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INSTHUCTIONS ON BACK OF V