P - 77115REQUEST FOR ELECTRICAL INSPECTION ���'_�'���
1�y � o�� 7 3 O � Minnesota Board of Electricity ,�,,
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 _� ry
(651) 642-0800 TTYIMRS 1-500-627-3529 wwtiv.eleciricity.state.mn.us u�3�
Describe -using the back of the white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoor Lig ing Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere $25 Supplemental Fee $20
401 to 800 Am ere $50 Transformers u to 10 KVA $10
Above 800 Am re $75 Transfortners over 10 KVA $ 20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li hGn $5
0 to 200 Am re $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes the Service and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$SO
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional ins ction Tri s $20
Each S stem Device or aratus @$.50 Investigative Fee
ADDITIONS TO THE GENERAL FEES Reins eclion Fee $20
MULTIFAMILY DWELLINGS PER UNIT TOTAL FEE �
3 to 12 UnRs @$5o Per Unft (minimum total fee is $20)
Each Additional Unit @$25 nas u�n Foa iNSaecroR use owiv
OTHER ADDITIONAL FEES
Lightin Retrofit $25 pef FiXtUfe I hereby certity that I inspected the elecUicai installation described herein on the dates stated:
Center Pivot i ation Boom $40 Rou�, �N oA*�
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites $5 F�"^� �"�CT10N , oare
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Special Inspection $30 per Hour `""'"`","°"""""`°
Special Inspection @ $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN
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�ate: Rough-in Inspection Required? ❑Yes �Jo Inspedion OtherThan Rough-In�Ready Now ❑Wiil Call
9���"�V You must call the inspector when ready! Date Ready: �� 3��
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address City
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Area Code
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—�Electrical Utllitv Address
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�ctor / Company Nam ConVactor License Number Master Elecfriaan or Power Limited Technician
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g Address (Contractor, Company or Owner Perfortning Installation)
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�rized Slgnature Contrador or Owner Perfortning Installation) lease Provide Two (2) Phone Numbers Including Area Code
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i�.� .r�r..cve��nwrnev • eneonnrci[rrwirirvrnov FR-O(M107A-75 fi.7.2004