P - 80133REQUEST FOR ELECTRICAL INSPECTION
1 l„ �� � 7� °- � Minnesota Board of Electricity —
� U � �� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� �' (651) 642-0800 TTY/MRS 1-800-627-3529
www.electricity.state. mn. us
Identity t� Work 6��� T m�`�i�eF r.t� .4 Fus'FS� Ta /j:1 � —.r��lyx L a nl c.. �/ .
�ew�`SREMODEL ❑ ADDITION�d REP R XC'� C— G�-�D �� �'�'O ��'7�1f G� t� /�j A—�G� C.! `«',7—
��� lt f�� lC l %'CG� .� 15�
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am re �$25 Su lemental Fee �$20
401 to 800 Am ere �$50 Transfort�ers u to 10 KVA �$10
Above 800 Am ere �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transfortner / Power Su I for Si ns / Outline Li htin �$5
0 to 200 Am re �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 includes the Service and/or Power Supply 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 Additional Inspection Tri s�$20
Each S tem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins fion Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to �2 Units c� �so Per Unit (minimum total fee is $20) ��
Manufactured Home Park Lots �$25 I hereby cerfity that I inspected the electrical installatan
Recreational Vehicle Park Sites �$5 f01GH1N
Se arate Bondi Ins 'on � $20
Special Inspection �$30 per Hour Fl""""sff`�10N _ __
FOR OFFICE USE ONLY
II�III {NII IIIII Nfll ll!{{ II�II {IIII {ill! lll! Ilfl
�E 1 t7 3 3 7 7 3 1 �E
�� l��_
18 MONTHS
����8 .�-�
I certii�r 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 Zp Code
l�r/ C.//��2 Tt� ST �a2C/� G,�'c/ fS"���,
Occupant
� F��
Power Supplier
�i �
���
: _F.2 � �1 c� r..� s
'�l� o�'C�a C
tor, Company or Owaer Pe
c.i(�'`� S f-1
rnractor, Comaanv or Own�
Phone
7�3 ���-�"��
F t�'�yiT i3 cs ur� rtl
[rac[or Ucense Number Master License Number
/-�0�3��5� .4i�v33�
GU � S o �
allation) Phone
l�
OF ELECTRICITY COPY INSTRUCTIONS ON BACK OF YELLOW COPY