P - 79712REQUEST FOR ELECTRICAL INSPECTION
e� ° Minnesota Board of Electricity `°�
� 1�-� � V- 4 4 7 � � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
, �� s�� (651) 642-0800 TTY/MRS 1-800-627-3529
www.electricity.state.mn.us ���p
IdentiTy the work covered hy this request:
❑ NEW EMODEL ❑ADDITION ❑ REPAIR
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES TraHic Si nal Standard �$5
0 to 400 Ampere �$25 Su lemental Fee �$20
401 to 800 Am ere �$50 Transformers u to 10 KVA �$10
Above 800 Am ere (� $75 Transfortners over 10 KVA �$20
IRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li h6n �$5
0 to 200 Am ere �$5 (,� ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 2D0 Am re �$10 Includes the Service andlor Power Suppty up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Unft �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri s�$20
Each Svstem Device or Aooaratus �$.50 Investiaalive Fee
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units (� $50 Per Unit
Each Additional Unit � $25
OTHER ADDITIO�
Li htin Retrofit �$25 r Fixture
Center Pivot Irri ation Boom �$4�
Manufactured Home Park Lots � $
Recreational Vehicle Park Sites �
S rate Bondin Ins 'on � $21
S ial Ins 'on �$30 r Hour
Special Inspection � $.31 per Mile
I herebv certiN that I inspected the
PoR OFFICE USE ONLY
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total fee is
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118
1 ceRi(y that I am 1he�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Route No.) City �P ��
2�� c,� �s�y s� �'�;d/e Ss�l�
Section Township ` Range , Fire No. CouMy �
OccupaM
L.ee ' �2. � G l
Power Supplier
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Electrical Contrador�KiqNa�(� ��
Mailing Address (Contrador, Company or Owner
Authorized re (C r�t m _
Phone
� --��-� 65
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Contractor License Number Master License Number
� 7ct6 S Os�s
ng Installation)
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fortnin nstallation) Phone
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RD OF ELECTRICfTY COPY INSTRUCTIONB ON BACK OF YELLOW COPY