P - 78062REQUEST FOR ELECTRICAL INSPECTION
1� J O 0-� 6 3 8❑ Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TfYIMRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW ❑ REMODEL O ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
GENERA FE S Outdoor Li htin Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5 �
0 to 400 Am re $25 Su lemental Fee $20
401 to 800 Am re $50 Transfortners u to 10 KVA $10
Above 800 Am re S75 Transformers over 10 KVA $ 20
CIRCUITS I FEEDERS Transformer / Power Su I fa Si ns / Outline Li htin $5
0 to 200 Am re $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes ihe Service and/or Power Supply up to 500 Amperes, All
AIARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins tion Tri s $20
Each S stem Device or A ratus $.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins 6on Fee $20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE �D
3 to 12 Units @$50 Per Unit (minimum total fee is $20)
Each Additional Unit @$25 Tws n�� Foa iNSaECroa usE orxr
I hereby ceAily that I inspected the electrical insfallation described herein on tlie dates stated:
OTHER ADDITIONAL FEES
Liahtina Rehofit (� $.25 cer Fixture
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NSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MON71i5 __ �
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I certify that I am the
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Rough�n InspecUon Required? ❑ Yes ❑ No Inspedion Other Than RougMn: ❑Ready Now Will Call
� You must call the inspector when ready! Date Ready:
CENSED CONTRACTOR � COMPANY ❑ OWNER and hereby request inspection of the electrical xrork at::
or te No.) Ciry Zip Code
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License Number
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