P - 79834REQUEST FOR ELECTRICAL INSPECTION
�` � Minnesota Board of Electricity
1, � 2 5 6�16 4��� 152� �n��ers�� A�e�ue S��te 5-128, Saint Paul, Minnesota 55104
(651) 642-OS00 TTY/MRS 1-800-627-3529
` www.electricity.state.mn.us " ''d'�
Identity the work covered by this request:
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR � �0��6 � ' � � � ��" ���
GENERAL FEES Outdoor Li hti Standard �$1
S RVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am re �$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10
Above 800 Am re �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su for Si ns I Outline Li hti �$5
0 to 200 Am ere (� $5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere �$10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Unit �$SO
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri �$20
Each S stem Device or Ap aratus �$.50 Investi tive Fee
ADDITIONS TO THE GENERAL FEES Reins ection Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units �$50 Per Unit (minimum total fee is $20)
Each Additional Unit �$25 wa ir+saECroa use auv
OTHER ADDITIONAL FEES �g_S�
Li htin Retrofit �$25 r Fixture J�� � r�� �L'
Center PNot Irri ation Boom �$40 �{�� P'y� �
Manufactured Home Park Lots �$25 I hereby cer61y that I inspected the electrical insfalletion described herein on tlie � shated:
Recreational Vehicle Park Sites � �H IN ��
Se rete Bondin Ins 'oo �
S ial Ins �on �$30 r Hour p""`'"'��"0N - 0A7E
S ial Ins 'on �$.31 r Mile ��� c-3
THIS INSTALlAT10N MAY BE ORDERED DISCONNECTED IF N T COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY
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� te: Rough-in Inspection Required7 ❑ Yes o Inspection Other Than Rough-In: eady Now ❑ wil Call
must call the inspector when readyl Date Ready:
I cerdfy that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of ihe electrical wak at
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Section Township A^ Range Fire No. County
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Power Supplier Addr
Electrical C ractor / ompan Name 1 Contrador License Number Master License Number
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Mai in ddress (Contractor, Canpan or wner Perfortning I Ilation) �-
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E -13 7/1/2000 BOMD OF ELECiAICRY COPY INSTFiUCT10N3 ON BACK OF YELLOW C PY