P - 77015REQUEST FOR ELECTRICAL INSPECTION
� Minnesota Board of Electricity `�
��� 4 7� 5 1 2 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3 =
www.electricity.state.mn.us �� O(, 3��
Identify the work covered by this request:
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR
GENERAL FEES
SERVICES I POWER SUPPLIES Traific Si nal Standard �$5
0 to 400 Am re �$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10
Above 800 Am re �$75 -- � I Transformers over 10 KVA �$20
CIRCUITS / FEEDERS �y n Transformer / Power Su for S' ns / Outline Li htin �$5
0 to 200 Am ere �$5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Ins 'on Trips Each Dwelli it �$8(
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri �$20
Each S stem Device or ratus �$.50 Investi tive Fee �-: .�.
ADDITIONS TO THE GENERAL FEES Reins
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units �$50 Per Unit
EeCh Additi0nal Unit � $25 wRira�cra+useowr
OTHER ADDITIONAL FEES
Li htin Retrofit �$.25 r Fixture
Center Pivot Irri tion Boom �$40
Manufactured Home Park Lots �$25 I nereb cemty ihat I
Recreational Vehicle Park Sites �$5 R01GM1N
Se rate Bondin I ion �$20
S ial In 'on �$30 r Hour """""�``"01
S ial In ' n�$.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED II
FOR OFFICE USE ONLY
I Illlll 111i111I{I IIIII Ilill Illil IIIII I II II III I INI
�E � 3 4 7 5 1 Z 4�F
����� �«
(minimum total fee is $20) 5,
installafian described herein on the dates stated:
w�
'1--�-- ' ��'� <
w�
� -� -�rs-
.ETED WITHIN 18 MONTHS
,
�� ri` r�' � a U3
Raquest Date: Rough-in Inspection Required? � Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now � Will Call
g�� �,'� �� You must call the inspector when �eady! Date Ready:
�
I certify that I am the � LICENSED CONTRACTOR ❑ COMP.ANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Sheet, Box, or Route No.) Ciry Zp Code
6 8 � F1,' K r N. F �,` 1
Section Township Range Fire No. Cou ty
.�b Q
Occu`pa�nt Phone
H a► Y` r c. � e L�c r� rr� 7� 3— S 7 i'? h 2(�-
Name
L 7' A
Mailing Address (Contrador,
13 - 0
Authorized Signature (ContrF
0
or Owner
or Owner Performing Installation)
�
E&00001A-13 /'1000 BOAFID OF ELECTRICITY COPY
/`I'1 S S p
Phone
�- a-��f7o
M19TNUC710N3 ON BACK OF YELLOW COPY