P - 77574REQUEST FOR ELECTRICAL INSPECTION
1� g�� r,� 4� 2 Minnesota Board of Electricity �-;
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
(651) 642-0800 TlY/MRS 1-800-627-3529 www.electricity.state.mn.us
Desc' -usin the back of the white co y'rf necessary - the work covered by this r uest: QD ���� �/
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GENERAL FEES Outdoor Liahtina Standard (� �1
SERVICES I POWER SUPPLIES
0 to 400 Am ere a$25
401 to 800 Am ere a$50
Above 800 Am re $75
CIRCUITS I FEEDERS
0 to 200 Am ere $5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CANTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or aretus $.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Each Additionai Unit @ $25
OTHER AD
Liqhtinq Retrofit Cal $.25 cer F
Traffic Signal Standard
Suoolemental Fee af� $
ONE & TWO FAMILY DWELLINGS, EACH UNIT
includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ion Tri s$20
Investigative Fee
Reins ion Fee $20
TOTALFEE
(minimum total fee is $20) � �
THISAREA FOR INSPECTOR USE ONLV
I hereby certiTy that I inspected d�e elecVical installaUon described herein on the dates stated:
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Special Ins ction $30 r Hour �P1RED'A8AND0NED oA�
Special lns ion $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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18564625
Rough-in Inspection Required7 ❑ Yes �JJo Inspedion Other Than Rough-In: Q�,Ready Now ❑ Will Call
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You must call the inspector when ready! Date Ready:
I certify that I am the�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and herebyrequest inspection of the electrical work at:
Job Sfte Street Address ��
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OwnedOccupant Name Please Pro�ride Two (2) Phone Numbers Incl 'ng Area Code
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actor, Co`,�� p ny or _Own
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4 OF VELLOW COPY
License
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BOARD OF ELECTRICIN COPY
ar Electricaan or Power Limited Technician
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Phone Numbers Including Area Code
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