P - 77290REQUEST FOR ELECTRICAL INSPECTION
/� (� Minnesota Board of Electricity '�°
1� 3 4 7�`�t H J 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 - _
www.electricity.state.mn.us
Identify the work covered by this request:
❑ NEW MODEL ❑ ADDITION ❑ REPAIR ,J r���' C! JZyQ,,��r
GENERAL FEES Outdoor ' htin Standard �$1
SERVICES / POWER SUPPLIES Traific Si nal Standard �$5
0 to 400 Am re �$25 Su lemental Fee �$20
401 to 800 Am re�$50 Transfortners u to 10 KVA �$10
Above 800 Am re (� $75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li htin �$5
0 200 Am re �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re�$10 Includes the Service andlor Power Suppty up ro 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 Ins ion Tri s�$20
Each S tem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ion Fee �$20
MUL31? A 21 Un�W�ELL� P rP�E�R UNI S��/�C�� C/���� im m total fee sL$ E ��
OTHER ADDITIONAL FEES
Li htin Retrofit �$25 r Fixture
Center Pivot Irri tion Boom �$40
Manufactured Home Park Lots �$25 I herety cer�
Recreational Vehide Park Sites � $5 /01GM1N
Se arate Bondin Ins ection �$20
S ial In ion �$30 r Fbur �"'�CfO"
S ial In ' n�$.31 r Mile
THIS �INSTALLATION MAY BE ORDERED DISCONNECTE
FOR OFFICE USE ONLY
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Request Date: Rough-in Inspection Required? ❑ Yes ❑ No Ins ectian Other Than Rou h-In:
�` p g ❑ Ready Now ❑�II Call
J`� � � S You must call the inspector when ready! Date Ready:
I certity 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 Township Ranae Fire No. Co ri
Occupa�t
Power Supplier �
Electrical Contractor / Comoanv Name
Mailing Address (Contractor, Company
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Authorized Sj nature (Contractor, Com
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Phone
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License Number � Master License
Installation)
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8 ARD OF ELECTAICITY COPY
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INSTRUCTIONS ON BACK OF YELLOW COPV