P - 77521REQUEST FOR ELECTRICAL INSPECTION � �
I���� o� 4 41 � 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
Describe -'ng the bac�C of the�e copy if ssary - the work covered by this quest:
�
GENERAL FEES Outdoor Li hting Standard $1
SERVICES I P WER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere $25 Sup lemental Fee $20
401 to 800 Am ere $50 Transformers u to 10 KVA $10
Above 800 Am re $75 Transformers over 10 KVA $ 20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li htin $5
0 to 200 Am re $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 Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri s $20
Each S stem Device or Apparatus $.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ection Fee $20
MULTIFAMILY DWELLINGS PER UNIT TOTAL FEE
3 to t2 units @$50 Per Unit (minimum total fee is $20) ` Qs C�i C�
EachAdditionalUnit@$25 rnisnREnFOaiNSVecTORUSeoNir � ��? �Y�
OTHER ADDITIONAL FEES �
Li htin RBtfOfit $.25 p2f Fixtufe I hereby certiy thal I inspeded the electrical installatian desaibed herein on ihe dates stated:
CeMer Pivot Irti tion Boom $40 RWGHIN �„�
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites $5 J^"� �"s�CT10N oA*E
Se arate Bondin Ins ion $20 L �--#�--�� 7—� .�"7
Special Ins ion @$30 per Hour Exe�aEOinanNO op�
Special ins ion $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS ____
�=�,r;�. : �...:_,
� ���� �� ��i �� ��� �� II (� (�� �� (�� �� ��� (� �� �� �� �� ���/� "�� �
I� � � . ��
1 8 2 0 4 412 �(/ � ��
��
Date: Rough-in Inspection Required? ❑Yes �yl�, Inspection OtherThan Rough-In: eady Now ❑Will Call
`� You must call the inspector when ready! Date Ready:
I certify that I am the ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Street Address C�,
� �7 " ��/e
To sh ection Range Fire No. Coun ��
Owner/O upant Name Please Provide Two () Phone Numbers Including Area Code
c,c�c.c � b -/ 3�. )
Electrica Utllity ElecVical U61ity Address
Contrador / Company Na� Conhador License Number Master Electrician or Power �imited Technician
vf O. License Number Q
7� � C
f�
ailing Address (Contractor, Company Own r erfoy�ing Installation) �
l Sc� � G� l� �lv'� u,� �� ��tS�' �`�
A ora ignature (Con or or er Perfortning Installation) Please Provide Two (2) Phone Numbers Indudi Area Code
- `� 6 � (763) �b°�oS
TRUCTIONS ON B � F YELL OPY BOARD OF ELECTRICITV COPV ra_nnnn�e_�c n. onn.