P - 76603REQUEST FOR ELECTRICAL INSPECTION =�}
2� 0 3��•,p,1 � 7 � Minnesota Board of Electricity �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-OSOOTTY/MRS1-800-627-3529www.electricity.state.mn.us ��
Describe -using the back of e white copy if necessary - th vered by this request/:
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GEN RAL FEES Outdoor Lighting Stan ard @$t
SFRVICES / POWER SUPPLIES Traffic Sipnal Standard (� $5
/ 0 to 400 Am ere a�2f✓
401 to 800 Am ere a$50
,, Above 800 Am ere $75
CUITS/FEEDERS
0 to 200 Am re
Above 200 Am re $10
AiIARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Additional Unit @
Center Pivot Irrigation Boom
Manufactured Home Par
Recreational Vehicle P k Si
Fee @ $
up to 10
over 101
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
(min total fee is $20) `� �
�' THIS AftEn FOR INSPECTOR USE ONLY
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I ere certMYtrrat I in�ted the elecUical inslallalion de�ibediierel/i on the es �'fa�d�
. WGHIN DATE
���
� INSPECTION ^ DATE
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TH I TA TION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rough-in Inspection Required?�es ❑ No Inspection Other Than Rough-In: ❑ Ready Now dl Call
� � 6� You must call the inspectar when ready! Date Ready:
I cert' that I am e�ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address City �
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Name /�
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ractor,f.pm�nyp� Owner Performing
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or
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Contractor License Number Master ElecVician ar Power Limited Technician
% /' � _ � ( j/�/' � License Number
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Please Pr ' e Two (2) Phone Numbers Including Area Code
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