P - 77328• , REQUEST FOR ELECTRICAL INSPECTION
1 3 4 7 518 Minnesota Board of Electricity
� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-OS00 TTY/MRS 1-800-62z352� ^ � - _
www.electricity.state.mn.us ��� ��,5 --D 1 � 8
Identify the work coveretl by this request:
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR LC� �-� �ti1.=^� �
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am re �$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transfortners u to 10 KVA �$10
Above 800 Am re �$75 Transfortners over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su I for S' ns / OuUine li hd �$5
0 to 200 Am re 8 o a ONE 8 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 Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additbnal Ins ection Tri �$20
Each S stem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ion Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE �. ��
3 to t2 Units �$5o Per Unit (minimum total fee is $20)
EeCh Additi0�el U�it �$25 f-0F INSPECTON USE/ONLV �.�, [,,�
OTHER ADDITIONAL FEES �G /1(/S tf E, ���"� r'�"�' �
Li hUn Retrofit �$25 r Fixture ` n
Center Pivot Irri tbn Boom �$40 �u`C�► -GU.�
Manuf2CtUfed HOmB POfk LOtS �$25 I hereby certily thal I inspected the elecMrical installation described herein on the dates shated:
Recreational Vehicle Park Sites � $5 �01G1'" °ATE
S rete Bondin I ion �$20
S ial Ins 'on �$30 r Hour `TM"""�CfON °"'E
S' I 'on �$.31 r Mile r G'�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFFlCE USE ONLY
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Request Date: Rough-in Inspection Required? ❑ Yes �.No Inspection Other Than Rough-In: ❑ Ready Now Will Call
��p�� You must call the inspector when readyl Date Ready:
I cerGiy at I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Roule No.) City Zip Code
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Section Township Range Fire No. County
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Occupant Phone
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Power Supplier Address
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Electrical Contractor / Company Name Contractor License Number Master License Number
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Mailing Address (Contrador, Company or Owner Perfortning Installation)
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Authorized SignaSyre�(Co actor, CgtnQal� or Owner Performing Installation) Phone
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BOAND OF ELECTRICRY COPY INSTAUCTIONS ON BACK OF YELLOW COPY