P - 76416(�c REQUEST FOR ELECTRICAL INSPECTION
2°� 1� ie 4 O V � Minnesota Board of Electricity �- :�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
- � (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Descri - ing the back of the ite coFy if nece - the work covered by this request:
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GEN FEES Outdoo bhtina Standard (o� 1
SERVICES I POWER SUPPLIES
0 to 400 Ampere $25
401 to 800 Am re$50
Above 800 Am ere $75
IRCUITS I FEEDERS
0 to 200 Am re $5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CANTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or aratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units af� $50 Per Unit
OTHER ADDITIONAL FEES
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irrigation Boom @ $40
Manufactured Home Park Lots (cil $25
Traffic Si nal Standard �$5
Su lemental Fee a $20
Transformers u to 10 KVA a$10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns I Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ection Tri s $20
Investi a6ve Fee
Reins ection Fee $20
TOTALPEE
(minimum total fee is $20) � D '
I hereby certi(y that I inspected the electrical installation described herein on the dales stated: I
ae rate esonam ms ion m�zu v �c
Special Ins 'on $30 r Hour ��E����� ���
Special Inspection $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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�^ 1� O ough-in Inspection Required? ❑ Yes a Inspection Other Than Rough-In: eady Now � Will Call
Li You must call the inspector when ready! Date Ready:
I certify that I am the � LICENSED CONTRACTO OMPANY ❑ OWNER and hereby request inspection of the electriql work at
Job Ske Address �
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Township , Section Ranae Fire No. Couni�
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✓ Electrical Utllfty Address
���Name� ' � � Cory�ctol Lia
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s(Cog(rad , \ y or er Pe rming Installa6on) � �
pnaW Con or P ortnirg In II 6on)
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ON BACK OW COPY BOARD OF ELECTRICIN COPV
Two (2) Phone Numbers Including Area Code
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Master ElecUician or Pawer Limited Technician
License Number
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iw� Phon Numbers Induding Area Code
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