P - 75948REQUEST �,OR El„�CTRICAL INSPECTION -�
I 1����� q, � g� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.elech-icfty.state.mn.us
Describe -using the I�ack of th�hfte 4opy'rf necessary - the work covere,d t}y thi�,,request:
SERVICES / POWER SUPPUES
o roAeo a�,�e� @ $zs
1 to 800 Am ere �$50
Above 800 Am re $75
CIRCUITS / FEEDERS
0 to Z00 Am $5
Above 200 Am re $10
ALARM, CAMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Ap ratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UN
3 to 12 Units @$50 Per Unit
Each Additional Unft @ $25
OTHER ADDITIONAL FEES
Lightlng Retrofit @ $.25 r Fodure
CeMer Pivot Irt19ati0n Boom a(� $40
Traffic Sianal Standard
Transformer / Power Su for S' rrs / Outline U htln $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNR
Inciudes the Service and/or Power Suppry up to 500 Am�res, All
Ciraiits and Two Inspection Trips Each Dwelting Unit @$80
Add'Nonal Ins on Td $20
Inv�tigative Fee
Reins on Fee @ $20
TOTAL PEE � �r"�
(minimum total fee is $20)
7MSAISAFORP6PEC�OqUSEpIbY
I hereby ceAdy tliat I h�spected ffie electrical ir�allabon d�i6ed herein on the dates sU
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_� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
FOfi pFPlCE USE 4NLY
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�— �� � I Rough-in Inspec�on Requhed? ❑ Yes ❑ No InspecUon Other Than Rough-In: ❑ Ready Now OVd10 CaII �
You must cefl the inapector when readyl Date Ready.
I certi(y that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY WNER and hereby request inspection of the electrical uvork at
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PIS'TRUCTfONS ON BACK OF YEILOW COPY / BpqRD OF ELECTRICITV CAPV Fttmmm e_�s a� �nnn
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NOTICETO: ��nerolWufng
Minnesota��Bo�rd of Electricity
Inspection Report Form
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Ciiy� State, ZIP F ��' M+ ,C d CounTy Requast for Inspecllan # Date Filed
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The following items are deviations from the accepted standards of construction at the above described premises.
Numbers after each item reference the applicable National Electrical Code sections.
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CORRECT'f'HE NOTED'AE�ICIENCIES and:
0 No�ify t�e in�tor for re-inspection before covering
�� (�;Re=lnspecfion wrill be made atthe final inspection
`: ,"� Sigrr�nd retum this form to the contract inspector when corrections have been c�mpleted,
_--�ut no laterthan
Corttract Inspector f � e' ,.� _ f�� Signature of Inafaller
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Address _. ': f .�
Date of Compllarrce f /��% �
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A copy of this report will become a permanent
ra�aPnfl�eN�mna� ,y = _, � record of this inspection at the Board `of
E -^. ,�% / � � � � � ,� ��'� EI2Ct�Clty. Form EB-00116-04 (6/99)
White — Installer Canary — Board of Electric/ity_ Pink —Area Representati�e � Green — Inspector
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