P - 77284n� REQUEST FOR ELECTRICAL INSPECTION
1�� O J�� 3 V (( I Minnesota Board of ElecVicity
L__� 1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
❑ NEW EMOD ❑ ADD ION 0 REPAIR Describe -using the back of the white copy'rf necessary - the wak covered by this request:
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GENERAL FEES Outdaor Liahtina Standard Cd S1
SERVICES / POWER SUPPLIES
0 to 400 Am ere $25
401 to B00 Am ere $50
Above 800 Am re 575
CIRCUITS I FEEDERS
0 to 200 Ampere @ $5
Above 200 Ampere Q$10
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus �$.50
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Paver Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dweliing Unit �$80
_LINGS PER UNI TOTAL FEE
$50 Per Unit (minimum total fee is $20) O��
Unit@$25 ,�nsu�,c«arta�c.oause r
I hereby ter6fy that I inspected the electrical insta�a6on described herein on the d�es sta0ed:
OTHER ADDITIONAL FEES � � �qa L�'�GQ
@$.25 per Fixture C.1 J L
� Special Inspection @$.31 per Mile
iIS INSTALLATION MAY BE OR[
I IIII il III II i�l (I iIi I! III ii IlI II III II III N� I�
1 7 0 9 9 3 6 7
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nequesc uare: Rpug�-in Inspection Required? I�X€s LI No I�spection Other Than Rough-In: OReady Nov�fll Call
/�� a� you must call the inspector when ready! Date Ready:
I certify tt�at I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Address (Street,� x,,�°� No. City Zip Code
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EB-00001A-14 8.1.2002