P - 77422REQUEST FOR ELECTRICAL INSPECTION
Minnesota Boa1t� of Ef�c�tricity ��
�� 3 4 7- 5 2 4 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TfY/MRS 1-500-62 -3529 =
www.electricity.state.mn.us ��v�— ��9g�
Identity the work covered by this request:
❑NEW �IEMODEL ❑ADDITION ❑REPAIR
0 to 400 Am re �$
401 to 800 Am re �
Above 800 Am ere �
CIRCUITS / FEEDERS
0 to 200 Amcere � �
)MMUNICATION, REMOTE CONTROL,
CIRCUITS OF LESS THAN 50 VOLTS
vstem Device or Aoparatus � $.50
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units �$50 Per Unit
Each Addi�onal Unft � $25
OTHER ADDITIONAL FEES
Li htin Retro�t �$25 r Fixture
Center Pivot Ir � ation Boom �$40
Manufactured Home Park Lots � $25
Recreational Vehicle Park SBes � $5
S rate Bondin Ins 'on � $20
S'al Ins ' n�$30 r Hour
Outdoor
Su demental Fee �$20 Q! l�/� `
Transformers u to 10 KVA C� $10
Transformers over 10 KVA � $20
Trar�sformer / Power Su I for Si ns / Outline Li htin �$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Tri s Each Dwelli Unit �$8(
Additional Inspedion Trips � $20
InvesNaative Fee
thatlinspected the electricalinstallalion
total fee is
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dates stated: I
S ial In 'on �$.31 r Mile �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED NOT COMPLETED WITHIN iB-MONTHS
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FOR OFFICE USE ONLY
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Reque�D te: Rough-in Inspection Required? ❑ Yes ❑ No Inspection OUier Than Rough-In:
�� O@ ❑ Ready Now ill Call
I4 You must call ihe inspector when ready! Date Ready:
I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
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Section TownsFiip Range Fire No. County
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Power Supplier q��e�
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Electrical Contractor / Com y Name Contractor License Number Master License Number
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Mailing Address (Contractor, Company or Owner Perfortning Installation) D9 � S L y' � N
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Authorized Si ture (Contrector, Company or Owner e rtning Installation) Phone
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E -13 7/1/2000 BOARD OF ELECTpICRY COPY INSTRUCTIONS ON BACK OF YELLOW COPY