P - 78427- • REQUEST FOR E,LE�TRICAL INSPECTION
Q Minnesota Board of Electriciry
.L � 3 4 7��� V '�'� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529
www. electrici ty. state. mn. us
IdentiTy the work covered by this request: I, �O_ �
❑ NEW REMODEL ❑ ADDITION ❑ REPAIR
/
GENERAL FEES Outdoor U htin Standard �$1
S VICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am re�$25 Su lemental Fee �$20
401 to 800 Am ere �$50 Transformers u to 10 KVA �$10
Above 8(� Am ere �$75 Transfortners over 10 KVA �$20
CIRCUITS / FEEDERS Transfortner / Power Su for Si ns / Outline Li hd ��.5
0 to 200 Am ere �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere �$10 Ir�cludes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional In ection Tri �$20
Each S em Device or ratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ection Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to �2 units �$5o Per unit (minimum total fee is $20) ��
Each Additional Unit � $25 F0H1NSPECTO""�ONLY
OTHER ADDITIONAL FEES
Li htin Retrofit �$25 r Fixture
Center Pivot Irri ation Boom �$40
Manufactured Home Park Lots �$25 I hereby certi(y �hac 1 inspec[ed the eleclrical installaaon described nerein on the dates sle0ad:
Recreadonal Vehicle Park Sites � $5 "0101'" °"'�
Se arate Bondi Ins 'on � $20 �
S ial In ion �$30 er Hour' FJLP�"01 �/ DA1F
S ial Ins ion �$.31 r Mile ��"�^����'( `' �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED I T COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY
I11111I IIIII IIIII IIIII illll 11111 }IIIl111i1 IIII IIII ��- ����
�E 1 3 4 7 3 2 e 5�E � l S d
Reque Date: Rough-in inspec[ion Required? ❑ Yes o Inspection Oqier Than RougMln: ❑ Ready Now ❑�II Call
�j �� D You must call the inspector when readyl Date Ready:
I ceRify that 1 am the; LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electr�al work at:
Job Address (Street, Box, or Route No.) City T�p Code
�. a,'"'1 "�1� v� ``�, 'R. �-�� S-S'�1 �-
Section Township Range Fj� No. County
y ,
� -
Occupan Phone
��� �:w�-c�. �l �03 -`I --�'�S
Power Supplier Addre
!!%.�� 6 �%
Electrical Contrador / Company e CoMractor License Number Master License Number
�t�� e- �i�. vw,n..w-�c w��=�5� �'..� O �
Mailing Address (Contrador, Company or Owner Performing Installation)
`a �o � Z. '�= �..,�-e 5�`rQs�- I�e •
Autlwrized Signature (Contract , Com y or Owner Performing Installation) Phone
�/�.-�._.,.- �\ 2- P1�S ti- d 6Zfl"�
EB-00001A-73 7/1l2000 BOARD OF ELECTAICITY COPY PISTRUC710N3 ON BACK OF YELLOW COPY