P - 76540p /� REQUEST FOR ELECTRICAL INSPECTION
1� 6 4 4� O��F � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-0800T1Y/MRS1-800-627-3529 www.electricity.state.mn.us
❑ NEW REMODEL ;O ADDITIO ❑ REPAIR c' -using the back of the white coQy if nece ry- the work covered by this request:
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CESIPOWER
to 400 Amcere
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Exh System Device or Apparatus E.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Li htin Retrofit $.25 r Fixlure
Center Pivot Irri ation Boom ¢10
ManWactured Home Park Lots B E25
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that I am the
Su lemental Fee $20
Transfortners u to 10 KVA $10 -
Transfortners over 10 KVA $ 20
Transformer I Power Su I for Si ns / Oulline Li h6n $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits a�d Two Inspec6on Trips Each Dwelling Unit @$80
Additional ins tion Tri s $20
investi afive Fee
Reins fion Fee $20
TOTALFEE �
(minimum total fee is $20) � S. s
TMS AREA FOR INSPECTIXI USE ONLY
i hereb�er4Jy that I inspecfed the electrical installa6on described herein on tlie dates sfated:
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IF NOT COMPLETED WITHIN 12 MONTHS
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Rough�n Inspection Required? ❑ Yes �b Inspedion Other Than Rough-In: eady Now ❑ N/11 Call
6 You must call the inspecla when ready! Date Ready:
�LICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of the elecUical work at:
IN87RUCTIONB ON BACK OF
E&OOOOtA-14 8.1. ZOp2