P - 81917REQUEST FOR ELECTRICAL INSPECTION
��� 1�'-F - 515 � Minnesota Board of Electriciry -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
���� (651) 642-0800 TTY/MRS 1-800-627-3529�
www.electricity.state.mn.us ��
Identity the work covered by this request: �
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR �
GENERAL FEES Out r Li hti Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 Su Iemental Fee �$20
401 to 800 Am ere �$50 Transformers u to 10 KVA �$10
Atwve 80� Am ere �$75 Transiormers wer 10 KVA �$20
CIRCUITS / FEEDERS Transtormer ( Power Su fa Si ns ! Outline Li hG �$5
0 to 200 Am ere �$5 ONE & 7W0 FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere �$10 Includes the Service and/or Power Suppty up to 500 Amperes, All
ALARM, COMMUNICATION, REM07E CONTROL, SIGNAI.ING Gircuits and Two Inspection Trips Each Dwellin Unit �$80
CIRCUITS, CIRGUITS OF LESS THAN 50 VOLTS Additionai Ins ection Tri s�$20
Each Svstem Device or Aooaratus �$.50 I�vestiaative Fee
Each Additionaf Unit � $
OTHER
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FOR OFFICE USE ONLY
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total fee is
herein on tl�e dates stated: i
��..5"G'l�
18 MONTHS �_
Request Date: Rough-in Inspectlon Required9 ❑ Yes ❑ No Mspection Otlier Than Rough-In: eady Now U Will Cell
� •�� � Q` You must call the inspector when readyl Date Ready: _
I certify that I am the LICENSED CONTRACTOfl ❑ CpMPANY ❑ OWNER and hereby request inspection of the elecirical work, at
.
rJob Address (Sheet, x, or Royte�fJo.) ` _ City � � Zp Code �/ _
� Occuparrt
UEPENDABLE
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Authorized Sionatura�fC
Company or Owner
Fire No. County �y
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Phone
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2887u
Con raaor License Number Mas r License Number
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Installation)
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OP ELECTRIGTY COPY �ON� BACK OF Y0.LOW COPY