P - 76362` � � REQUEST FOR ELECTRICAL INSPECTION
1� O� 0`� � 6 3� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTYIMRS 1-800-627-3529 www. electricity.state. mn. us
Describe -using the back of the white copy if necessary - the work covered by this request: c( R�a,t,
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GENERAL FEES Outdoor Li htin Standard $1
SE VICES I POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere $25 Supplemental fee $20
401 to 800 Am re $50 Transformers u to 10 KVA $10
Above 800 Am ere $75 Transformers over 10 KVA $ 20
CIRCUITS / FEEDERS Transformer I Power Su I for Si ns I Outline Li htin $5
0 to 200 Am ere $5 �9�t � ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes the Service and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CANTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Addflional Ins ection Trips $20
Each Svstem Device or Aooaratus f�a $.50 Investiqative Fee
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL
Liqhtinp Retrofit C� $.25 per Fi�Aure
Special Inspection $30 per Hour
S ecial Inspection a$.31 per Mile
THIS INSTALLATION MAY BE
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18204636
TOTALFEE // � S
total fee is $201 T �
1 insoeded the electrical inslallaGon descnbed herein on the dates stated:
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WITHIN 12 MONTHS __
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Date: Rough-in Inspection Required? ❑Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call
T/ o/� b You must call the inspector when readyf Date Ready:
I certi(y that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY C
Job Site Street Address
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Township Section Range
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Electncal Utllity Electrical Utility Ac
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and hereby request inspection of the electrical work at:
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Contractor / Company Name Contrador License Number Master Electrician or Power Limited Technician
License Number
Mailing Address (ConVactor, Company or Owner PerformingJnstallation)
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Aut riz Signature nt r er Performing Installation) Please Provide Two (2) Phone Numbers Including Area Code
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