P - 79566` REQUEST FOR ELECTRICAL INSPECTION
1 1� � 7 2 3� Minnesota Board of Electricity =
� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
, � ���� (651) 642-0800 TTY/MRS 1-800-627-3529
www.electricity.state.mn.us
Identify the work covered by this request: /J �� �} �� /i �� v U` !
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❑NEW REMODEL ❑ADDITION ❑REPAIR ���Clti� ��Q�ZI
GENERAL FEES Outdoor Li htin Standard �$1
RVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am re �$25 Su lemental 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 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 Trios Each Dwellina Unit �$80
�UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus �$.50
ADD{TIONS TO THE GENERAL I
.TIFAMILY DWELLINGS (PER UNI�
3 to 12 Units �$50 Per Unit
Each Additional Unit � $25
OTHER ADDITIONAL FEES
Liahtina Retrofit � $25 oer Fixture
Manufactured Home Park Lots
Recreational Vehicle Park Site:
Hour
total fee is
the electrical installation descnbed I�rein an d�a dates stated:
THIS INSTALLATION MAY BE ORDERE� T COMPLETED WITHIN 8 MONTHS__
FOR OFF�E USE ONLY
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R�s]�ate: ., Rough-in Inspection Required? ❑ Yes o Inspection Other Than Rough-In: ❑ Ready Now H Call
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' V <% You must call the inspectorwhen ready! . Date Ready:
i certity that I am the' LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspecGon of the electrical worlc at
Job Address (Street�QQx w Route No,� /� Cityn _ /J _ , Zip Code
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ntrac►or / Company Name
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iign t e (CoMractor, Comp
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7/1/2000
Fire No.
Phone
ELECTRICfTY COPY
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License Number
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INSTfiUC710l� ON BACK OF VELLOW COPM