P - 78701REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electriciry
1� 3�, 2� 7 3 5 .� 1821 Universiry 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:
p NEW REMODEL ❑ ADDITION ❑ REPAIR � � i ��- / (��' �
GENERAL FEES Outdoor Li hb Standard �$1
SERVICES I POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am ere �$50 Transformers u to 10 KVA �$10
Above 800 Am re �$75 Transformers over 10 KVA �$20
C CUITS / FEEDERS Transfortner / Power Su for Si ns / Outline Li htin �$5
0 ro 200 Am ere � ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere �$1 Includes the Service andlor Power Suppty up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelli Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additlonal In ction Tri �$20
Each tem Device or A retus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Rein 'on Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE �
3 to 12 Units C� $50 Per Unit (minimum total fee is $20) � d
Each Additional UnA � $25 F0" �`�`0" "� °NLV
OTHER ADDITIONAL FE S
Li htin Retrofit �$25 r Fxture
Center Pivot Irri tion Boom �$40 f+� '
Manufactured Home Park Lots �$25 I hereby ce that I inspected �he electrical irslalla6on described herein on the da�s s�ted:
Recreational Vehicle Park SRes �$5 'ro"�"'" DA7E
Se arate Bondi In ion �$20 —Z� �3
S ial Ins ection �$30 r Hour """` "�E°70N �p °�'�
S ecial Ins ection �$.31 r Mile � 7—�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WRHIN 18 MONTHS
FOR OFFICE USE ONLY
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Reque Date: Rough-in InspecUon Required? es ❑ No Inspeclion Other Than Rough-In: ❑ Ready Now ill Call
You must call the inspector when ready! Date Ready:
certify at I am th LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job ddress (Street, Box, or Route�N,�o.) City Zip Code
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Section Township R nge Fir No. County
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Occupant r Phone
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Power Supplier Address
EI ri ConVador Company Name ' C trd�tor nse Number Master License Number
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M' g A ess o trador, Compan `r ner Performing In II tfon)
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Autho ' ed ignatur ntr or, ompany or Owner Pe ormi g lation) Phone
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EB-OOOOY/C73 7/1/2C00 OARD OF ELECTRICITY COPY INSTRUC710NS CK OF YELLOW COPY