P - 78749. REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity °"�
`1 �� 4 7� 3 2 3 °�� 1821 University Avenue Suite S-128, Saint Paul, Mi nes a 1 4
(651) 642-0800 TTY/MRS 1-800-6273529
www.electricity.state.mn.us J�L
Identify the work covered by this request ' �
❑ NEW ❑ REMODEL ❑ ADDITION '�flEPAIR
0 to 400 Am re �$2:
401 to 800 Am re �;
Above 800 Am re � y
RCUITS / FEEDERS
to 200 Am ere � $5
Above 200 Am re � 9
ALARM, COMMUNICATION,
CIRCUITS, CIRCUITS OF LI
Each Svstem Device or
3to12
iS THAN 50 VOLTS
PParatus � $.50
'0 THE GENEFAL FEES
�ER UNIn
Unit
?5
ADDITIONAL FEES
Manufactured Home Park Lots � $25
Recreational Vehicle Park Sites � $5
Separate Bonding Inspection � $20
Special Inspection � $30 per Hour °'
Special Insoection � $.31 oer Mile
THIS
Outdoor Liahtina Standard �
Su lemental Fee � $20
Transformers u to 10 KVA �$10
Transformers over 10 KVA � $20
Transfortner / Power Su for Si ns / Outline Li hti �$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Insoection Trips Each Dwellina UnA �$80
Fee �
(minimurrn total fee is $20) �.S /,�
I INSPECTOIi I� ONLY
.vp 1��� �� /�� .��,�
�rebY ceitiN ihat I in��ted the electrical�ratadatbn described herein on�e detes sfeted:
qQ � ,��
----- --- — — — — — — 18 MONTHS
FOR OFFICE USE ONLY
I Illill IIlII Illli lilli Iliil 11111 IlIII Ifl1i IIII 1111 ��f��
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Request Date: � Rough-in Inspectan Required? ❑ Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now 0 wN Ceq
'� � You must call the inspector when readyl Date Ready:
1 certi(y tl�at I am the ❑ LICENSED CONTRACTOR ❑ COMPANY �OWNER and hereby request inspection of the electrical work aY.
Job Address (Street, Box, or Route No.) City Zip Code
?! cc� F�t lk�'`�' Ssy 3.2...
Sec[ion Township Range Fire No. CouMy '
� �
���I�-IL►t �� Pho / �(/V'°�7 / r
Power Supplier Address ��
Electrical Contrador / Company Name CoMractor License Number Master License Number
Mailing Address (Contrac[or, Company or Owner Perfortning Instatlation)
Authorized Signature (Contractor, Company or Owner Pertortning Installation) Phone
EB-00001A-13 7Hl2000 BOARD OF ELECTRICRY COPY INSTRUCTIONS ON BACK OF YELLOW COPY