P - 77103REQUEST FOR ELECTRICAL INSPECTION -�'��
1� 910 � O J O � Minnesota Board of Electricity �- �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
, �'
(651) 642-0800 TTY/MRS 1-500-627-3529 www.electricity.state. mn. us
Describe -usin the back of the white py if necessary - the work cover by this request:
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GENERAL FEES Outdoor Li hting Standard @$1
SERVICES I POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere @$25 Supplemental Fee $20
401 to 800 Am re $50 Transformers u to 10 KVA $10
Above 800 Amoere an $75 Transformers over 10 KVA (� $ 20
tM, COMMUNICATION, REMOTE CONTROL, SIGI
:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
Additional Unit
Center Pivot Irrigation Boom �
Manufactured Home Park Lots
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ection Tn s$20
Investi ative Fee
Reins ection Fee a $20
TOTALFEE
(minimum total fee is $201
electrical installaGon described herein on�� sta� I
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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uace: Rou h-in Ins ction Re uired? ❑Yes No Ins
g pe q pecGon Other Than Rough-In: eady Now � Will Cali
/Q '�/�0 L� You must call the inspector when ready! Date Ready:
I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereb�request inspection of the electrical work at:
Job SRe Street Address � � � `� �
S� ��c es STN� �' l 1 c�e
Township Section Range Fire No. C nty
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OwnedOccupant Name Please Provide Two (2) Phone Numbers InGuding Area Code
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Elechical Utility Electrical Utility Address
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, �ompany or ner
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:ontra r License Number Master Electrician or Power Limited Technician
� / � License Number
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Please Provi Two (2) Phone Numbers Including Area Code
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