P - 81651REQUEST FOR ELECTRICAL INSPECTION
1('�/� Q �° Minnesota Board of Electricity -
� V+`t V- 6 5 3 ���° �821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
m (651) 642-0800 TTY/MRS 1-800-627-3529
' www.electricity.state.mn.us
Identity the work covered by this request: �� ��- �`'� f� ��� (�
❑NEW ❑REMODEL ❑ADDITION REPAIR �D ,iII!,��/C-(O(,r �
GENERAL FE S Outdoor Li htin Standard �$t
SERVICES / POWER SUPPLIES TraTiic Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10
Above S00 Am ere �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li htin �$5
0 to 200 Am ere �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service andlor Power Suppiy up to 500 Amperes, All
ALARM, COMMUNICATfON, REMOTE CONTROL, S{GNALING Circuits and Two Inspection Tri s Each Dwellin Unit �$SO
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Tri s�$20
Each S stem Device or A aratus (� $.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins tlon Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to t2 units �$5o Per Unit (minimum total fee is $20) • Sa
Each Additional Unit � $25 F0"'"�COfl `�E °NLV
OTHER ADDITIONAL FEES
Li hti Retrofit �$25 er Fixture
Center Pivot I' ation Boom �$40
ManufBCtured Home Park Lots �$25 I hereby cerG(y that I inspected ttre electrical installation described herein on the ��:
Recreational Vehide Park SRes �$5 P01GX1N �'�
Se arate Bondin Ins 'on � $20
S ecial Ins ection �$30 er Hour """'"�`'"10N °��
S'al Ins ion �$.31 r Mile —�l �
__ THISJ�ISTALLATION M/�1X BE ORDERED Q�SCDl�1NECTEp IF_dQI C9�APLETE2INJTHId 1$ MONTHS_ _
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I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Address (SVeet, Box, or Route No.) Ciry 2ip Code
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Section Township Range Fire No. Cou
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Oc�ypant Phone
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ower upp ier Address
- 286
EI 'cal Contractor / Company N�ame Contractor License Number Master License Number
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Mailing Address (Contractor, Company or Owner Pert rtning Installation)
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Authorized Signature (Contractor, Com n or in Instal ation) Phone
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EB-00001A-13 7/1/2000 � � � BOARD OF ELECTHICRY COPV � INSTFiUCTIONS ON BACK OF YELLOW COPY