P - 79591REQUEST FOR ELECTRICAL INSPECTION �
� � � � � � � � Minnesota Board of Electricity �
� � �' 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
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, �,,• �� (651) 642-0800 TTY/MRS 1-800-627-3529
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www.electricity.state.mn.us
Identity the work covered by this request:
❑NEW ❑REMODEL ❑ADDITION ❑REPAIR ��—L'(,,L I �CLrI QSb%� (C VP.✓I,n.�u,� �D7'L �'�" � �(1 YPL
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to S00 Am ere �$50 Transformers u to 10 KVA �$10
Above 800 Ampere �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li htin �$5
0 to 200 Am ere �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service ancVor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelli Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Tri s�$20
Each S siem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ction Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE �
3 to 12 Units �$5o Per Unit (minimum total fee is $20)
Each Additional Unit �$25 wR INSPECTOR USE ONLY
OTHER ADDITIONAL FEES
Manufactured Home Park Lots �$25 I hereb ce ' that I inspected the electrical installatbn desa�ed herein on the tlates slated:
� � Special Inspection �$30 per Hour _ I I"'"" "�' `"""��
� Sn�ial Insoection �$ 31 oef Mil@ � � ���^ �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
—� FOR OFFICE USE ONLY
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Request Date: Rough-in Inspection Required? ❑ Yes No Inspection Other Than Rough-tn: ❑ Ready Now i�l Call
� You must call the inspector when ready! Date Ready:
I cerfify that I am the �LICENSED CONTRACTOR ❑ COM and hereby request inspection of the e�ectrical work at:
Job Address (Stree Box, or Route No.) �ity ZiP �ode
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Section Townshio Ranna Fc.a � r.,,��.,n,
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Power Suonlier e,� .e� �
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(Contractor, Compan or Owner Performing Installation)
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License Number � Master License Number
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ES-00001A-13� 7/7/2 BppRp OF ELECTRICITY COPY INSTRUC710NS ON BACK OF YELLOW COPY