P - 78460REQUEST FOR ELECTRICAL INSPECTION
'�, J��- � 5 5� Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� � (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ N EMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
�30b ( � - _
GENERAL FEES Outdoor Liqhtinq Stan ard (� $1
0 to 400 Am re $25
401 to 800 Ampere @ $50
Above 800 Ampere @ $75
CIRCUITS I FEEDERS
0 to 200 Am re $5
Above 200 Ampere �$10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus �$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Per Unft
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Li htin Retrofit $.25 er FiMure -
Center Pivot Irri ation Boom $40 .
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites $5
arate Bondin Ins tion $20
S ial Ins tion $30 r Hour
S ial Ins tion $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DIS�
I�II IIIII IIIII II!II II II II�II IIIII �I� �� I�
1 5 31 0 5 5❑
Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
Transfortner I Power Supply for Siqns I OuUine Ligh6ng �a? $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes Me Service andlor Power Supply up to 500 Amperes, All
Cirouits and Two Inspection Trips Each Dwelling Unit � 580
Reins fion Fee $20
TOTAL FEE /�
(minimum total fee is $20) Q�Q
TWS MEA Fpi INSPECiOR USE O�dY
I hereby c�Gfy Mat I inspected the elec6ical insfatla6on despibed Iwein on the dafes sf�ed:
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Request Date: Rough-in Inspection Required? ❑ Yes �lo Inspection Other Than Rough-In: ❑Reedy Now 1]NMII Call
`v�- ��� You must call the inspecla when ready! Date Ready: �J
I certi(y that I am 1he�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of tlie elecfical work at:
Job Site Address (Street, Box, w Route No.) Ciry n Zip Code
S� � � 1/ h/'�11 L�7 �I (l 11C� ���i�
Ham �ake, MN !
i'�3)S����LS � )
Mast� Eieanaan a
License Number
INE7RUCTONB ON BACK OF YELLOW G�h�� BOA�2D � ELECTRICITV CAPV EB-0OOO1M14 8.1. 2002