P - 80179REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
� 1-396-� �J6 � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -
' (651) 642-OS00 TTY/MRS 1-800-627-3529
www. electricity. s ta te. mn. us
Identrfy the work covered by this request:
❑'f�EW ❑ REMODEL ❑ ADDITION ❑ REPAIR
GENERAL FEES
SERVICES / POWER SUPPLIES
0 to 400 Am ere �$25
401 to 800 Am ere �$50
Above 800 Am ere � $75
CIRCUITS / FEEDERS
0 to 200 Am ere �$5
Above 200 Am ere � $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or aratus �$.50
ADDITIONS TO THE GENERAL FEE:
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units (� $50 Per Unit
Center Pivot
Park Lots �
XCEL ENEROY SAVER'S SWITCH
Outdoor Li htin Standard � $1
Traific Si nal Standard � $5
Su lemental Fee � $20
Transfortners u to 10 KVA �$10
Transfortners over 10 KVA � $20
Transformers / Power Su I for Si ns / Outline Li htin �
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Irxludes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$E
Addi�onal Insoection Trips � $20
i�
TOTAL FEE
use aw�v
I hereby certiy Mat I inspected the elec[rical installatbn OescriOed herein on ihe tlates stated:
ROUGHIN DATE
FlNALINSPEC110N � UATE
�� S =2 -�3
FOR OFFICE USE ONLY
1(I�I�I IIIII I�III (II�I �III� � �� � �� I�I
* 1 3 9 6 1 5 6 0* �
t,� �.�
Reque�$�ro2 Rough-in Inspection Required? ❑ Yes [�No Inspection Other Than Rough-in: �Ready Now ❑ Will Call
You must call the inspector when ready! Date Ready:
I certily that I am the LjS LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Address (St��' so����� ��E 01y FRIIXEY zip �e 55,32
��
Section Township Range Fire No. County AN�A
Occuq�n� s, _ ,N A�Y Phone
LiFiC.7W
Power Supplier ddress
�. ewe�v 9
,
ElectricaHU tNr,aTcto�r�om�an�C am��T'� Contractor Lice�ns�e N�um$b8e3 Master License Number
ciK
Mailing !�(1� ��Sr �pC,�ip�ny�y0yvpe; PEr(p��$ I tio� �114
LdUU 1(.7FilALhi(JAU t5P1 A
Authoriz ' nature (�ractar, ompany or Owner Performing Installation) Phone
851 646-2911
E&00001A-13 7/1/2000 BOARD OF ELECTRICITY COPY INSTRUCTIONS ON BACK OF YELLOW COPY