P - 81897REQUEST FOR ELECTRICAL INSPECTION
� - ��� � - � H � e Minnesota Board of Electricity ''°-�
°'� g� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
�� e (651) 642-0800 TTY/MRS 1-800-627-3529
www.electricity.state.mn.us
Identify the work covered by this request: �
❑ NE4V ❑ REMODEL ❑ ADDIT{ON ❑ REPAIR � �
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to S00 Am ere �$50 Transformers u to 10 KVA �$10
Above 800 Am ere �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su I for S' ns / Outline Li Min �$5
0 to 200 Am ere �$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 DweNin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri s�$20
Each Svstem Device or Aoaaratus �$.50 Investiaa6ve Fee
OTHER ADDITIONAL FEES
Retrofit � $25 oer Fixture
� $� {1Cf HOUf
� $.31 per Mile
_LATION M�
total fee is
herein on Ihe dates slated:
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FOR OFF�E USE ONLY
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Request Date: Rough-in InspecMion Aequired? ❑ Yes ❑ No Inspection Other Than Rough-In: Ready Now � Will Call
' �� Q You must call the inspector when readyl Date Ready: �
I cerlify that I am the ICENSED CONTAACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Route o.) Cily Zip Code
,� � `3�
n Township �� Fre No. County
Oc�cupaM Phone
7�3- 7d'o-��3
Power Supplier Address
E{ectrical Contract 7 mp Name CoMrador License Number Master License Num r
DEPEND BLE ELECTRIC. 11`1C• �a 3� �
I r �n erfortning Installation)
C�en Rapids, MN 433
Authorized ' re(CoMractor, Company a Own§r�Perfortning Installation) Phone
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EB-00001A-13 7/i/2000 BOAfiD OF ELECTFtlCITV COPY IN37AUC110NS ON BACK OF YELLOW COPY