P - 79568REQUEST FOR ELECTRICAL INSPECTION
' °: �e Minnesota Board of Electriciry �
1� 2 3 2� 1 H`t `� � 182� University Avenue Suite S-128, Saint Paul, Minnesota 55104
�;
(651) 642-0800 TTYIMRS 1-800-627-3529
www.electricity.state.mn.us ��� '� '
Identity the work covered by this request: °
W �'� i�1Ts'l� �2� ���e� ��
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR �
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 D � � Su plemental Fee �$20
401 to 800 Am ere �$50 Transformers u to 10 KVA �$10
Above 800 Am ere �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su for Si ns / Outline Li htin �$5
0 to 200 Am re �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 2� Am ere �$10 Inciudes the Service andlor Power Supply up to 5� Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin UnR �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri s�$20
Each S stem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ion Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE d
3 to 12 Units �$50 Per Unit (minimUm tOtal fee IS $20) �
EaCh Add'ItiOnei Unit �$25 WH INSPECTOH USE ONLY
Center Pivot Irri atlon Boom �$40
Manufactured Home Park Lots �$25 I hereb ce�i that I inspected the electiical installation described herein
Recreational Vehicle Park Sites �$5 fl01GH1N
Seoarate eondin4 Insaect�ron �$20 A A C A�
I Ins ection �$30 er Hour iV V V iGf `"""�`"p
I Inspection � $.31 per Mile
> INSTALLATION MAY BE ORDERED DISCONNECTI
�
I certiiy that I am the �.412E1Q�D CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspectioo- of the electrical wwk at:
Job Address (Street, Box, or Route No.) Ciry Zip Code
-
.Si'�`l3Z
Section Township Han� � Fire No. ounty
��
OccupaM Phone
Z�Z- 7�0- q�
Power Supplier �
S � '1�•
Electrical Contrador / C pany Name Contractor lJcense Number Mester License Number
(1� .�� F' 0 0,.�-E�, .,: (� a�� � C� b�t Q 4 Q�'1��Ss'1
(Contractor, Company or Owner Pertorming Irtstallation)
�
iture (Contr , Ca any or Owner Performing Installation)
�u,r✓ 2 - 22l -1 �7�i
/pppp . BOAHD OF ELECTtiICITY COPY
.+.
' �.J 1 1 • / dw / I
INSTRUCT10N3 ON BACK OF YELLOW COPY