P - 76600REQUEST FOR ELECTRICAL INSP CTION
Minnesota Board of Electrici ��.,..O14%;� � ```
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.r� 1821 Universi Avenue Suite S-128, aint Paul, Minneso
_ � (651) 642-0800 TTY/MRS 1-800-627-3529 =
www.electricity.state.mn. us
Identify the work vered by this request: -
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR
GENERAL FEES Outdoor Li htin Standard (� $1
SERVICES / POWER SUPPLIES Traitic Si nal Standard �$5
0 to 400 Am re �$25 Su mental Fee �$20
401 to 800 Am re �$50 Transformers u ro 10 KVA �$10
Above 800 Am re �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su for Si ns / Outline Li htin �$5
0 to 200 Am ere �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri ��20
Each S stem Device or ratus �$.50 Investi tive Fee
ADDITIONS TO THE GENERAL FEES Reins �on Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to t2 units �$5o aer Unit (minimum total fee is $20) /� S
Each Additional Unit � $25 � �� � ��
OTHER ADDITIONAL FEES
' Min Retroffi � $25 r Fixture
Center Pivot Irri tion Boom � a40
ManUfaCtufed Home Pafk LotS �$25 I hereby ceAify that I inspecl the electrical installation described herein on the dates stsled:
Recreational Vehicle Park Sites � $5 "W0H ��
S rate Bondin I ' � $20 Q,�ZV J4 � - /_� - ���'
S �al Ins �on � $30 r Hour """�' ��
'al I ' � $.31 r Mile ��1 /��—��
_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY / � �-✓I � °�
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Request Date: Rough-in Inspection Required? es ❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call
9 g `� You must cali the inspector when readyl Date Ready:
I certi(y that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Rou[e No.) C�y Zp �e
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Section Township �O Range Fire No. County
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Occupant ��rb- one
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Power Suppli r A ss
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Electrical Contractor �any Nam� � Contractor License Number Master License Number
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Mailing Address (Contrad ompany or � Perfortning Insit
A ed Signature (Contractor, Corr�pany or Owner PeAorming
Phone
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INSTRUCTONS pN BACK OF �
°`T��� Mir�� ��ta Board of Electricity
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,,,�,�' Inspection Report Form
NOTICE T0: '^$'�"��°f�^^�
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City, Stata, Zip // County R uaM�to,r%� pec6on # Date Fled
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The following items are deviations from the accepted standards of construction at the above described premises.
Numbers aftw each item reference the.applicable National Electrical Code sections.
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CORRECT TH TED DEFICI�IV�IES and: �''� ` 3���' 1"``� �r�U'� �--. '
❑ Notify the inspe�cr�f6�4re�spection before covering
�7Re-Inspe�tion HhlFbe'rtiade-at the final inspection
� LJ Sign and retum this form to the contrar,t-inspector w�ien oomections have been completed,
but no later than : "�
Contract Inspedor J �.- _-$(gnature o/ Insfsller :
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�� Date of Compliance ��' ///���-�--��
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��� Lp A copy of this report wil) become a permanent
r�N��� record of this inspection af the Baard of.-,.
f' ??` S�? Electricity. Form Ee-ooa�s-oa �s�ss� �
White - Installer Canary - Board of Electriaty Pink - Mee Representadve _ Green - Inspec�r
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