P - 81838REQUEST FOR ELECTRICAL INSPECTION
�� • Minnesota Board of Electricity °W�
1-110 - 2 4 5 -� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
` (651) 642-0800 TTY/MRS 1- 27-3529
www.electricity.state. -
Identify the work covered by this request: ^ ��C/C��
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPA
N
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Tra�c Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am ere �$50 Transformere u to 10 KVA �$10
Above 800 Am re �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer I 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 and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING CircuiGS and Two Inspection Tri Each Dwelli Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS AddiUOnal In ion Tri s�$20
Each S stem Device or aratus �$.50 Investi tive Fee
ADDITIONS TO THE GENERAL FEES Reinspection Fee �$20
3 to 12 Units �$50 Per Unit
Each Additional Unit � $25
OTHER ADDITIOP
Lighting ReVOfit � $25 per Fixture
Center Pivot Irriaation Boom � $4C
I hereby cer6N that I
total fee is
Se rate Bondin Ins ion �$20
S ial Ins 'on �$30 r Hour `x" °"'�
S' Ins 'on �$.31 r Mile '-�9— C�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
�R OFFICE USE ONLY
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Fiequest Date: Rough-in Inspection Required? ❑ Yes ❑ No Inspection Other Than Rough-In: eady Now ❑ WII Call
�� ' V/ You must call the inspec[or when readyl Date Ready:
I certi(y that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Ro e No.) Ciry �/`/Li(iC�1� �P ��
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Section Township Range Fire No. Counry � �
� Occupant
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Phone
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Electrical Contracto( / Company Name CoMractor License Number
EPENDABLE ELECTRIC, IN6. ���
'li A f�C o or r Perfortning Installation)
eon Rapids, MN 55433
Authorized Signature or, Company or Owner P ing Installation) PFw
.
EB-00001A-13 7/7/' NO BOARD OF FIECTRICITY COPY
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MS7HUCTpNB ON BACK OF YELLOW COPY