P - 76436REQUEST FOR ELECTRICAL INSPECTION �
L�� 3�,� °� 8 1 4 � Minnesota Board of Electricity ��
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -• �'
(651)642-0800TTY/MRS 1-800-627-3529 www.electricity.state.mn.us ��s�
Describe - ing the back of the white copy if necessa - the work covered by this request:
� '
GENERAL FEES Outdoor Lightin Standard @$1
SERVIC€S / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Amcere na $25 Su�olemental Fee (� $20
Above 200 Am ere a$10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Ao�aratus l� $.50
3 to 12 Units @$50 Per Unit
Each Addftional Unit @ $25
OTHER ADDITIONAL FEES
Liqhtina Retrofit a(� $.25 cer Fixture
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns / Outline Li htin $5
& TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unft @$80
Additional Ins tion Tri s$20
Investigative Fee
Reinspection Fee $20
TOTAL FEE � Cx"�
(minimum total fee is $20)
misnaEnFORwsaecroaus on�r
n
I hereby certify ihat I inspected ihe elecfrical inslallation described herein on the dates stated:
RWGH IN pATE
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Recreational Vehicle Park SRes $5 FIN�L MSPECTKKJ o�,e
Se arete Bondin Ins ction $20 � � "'G
S eciallnspection $30p2rHouf exaiaeornenr+ooNeo onTe
S ecial Ins ion $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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va[e: Rou h-in Ins tion R uired Yes ❑ No Ins
'� I�� g pec eq pection Other Than Rough-In: ❑ Ready N Will Call
� You must call the inspector when ready! Date Ready:
I certify that I am the�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job S' e Street Address C'
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Township Section Range Fire No. County
Own r/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
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Electrical Udlitv Electrical 'Ikv Address
/ComoanvName
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umber Master E�ectnclan or
� License Number
Wlease Provide Two (2) Phone Numbers
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