P - 81941REQUEST FOR ELECTRICAL INSPECTION
��� 2 8� O 0 8 � 8'21 U over ty Aveoue S tte'S 28, Saint Paul, Minnesota 55104
A (651) 642-0800 TTY/MRS 1-800-627-3529 �
www.electricity.state.mn.us " '
Identity the work covered by this request: / �
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR " ` " — �, C ` � � � y
GENERAL FEES Outdoor Li hti Standard �$1
SERVICES / POWER SUPPIIES Traffic Si nal Standard �$5
0 to 400 Am re �$25 Su lemental Fee �$20
401 to 8� Am ere C$50 Transformers u to 10 KVA �$10
Above S00 Am re �$75 Transformers over 10 KVA f� $20
CUITS / FEEDERS � Transformer / Power Su for Si ns I Outline Li htin �$5
0 to 200 Am re �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere �$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 Additional Ins ection Tri s�$20
Each S stem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ' n Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE �
3 to 12 Units �$50 Per Unii (minimum total fee is $20
EdCh Additi0nal Uf1it �$25 �on i�+srecroR use orav
OTHER ADDITIONAL FEES
Li htin Retrofit � $25 Fixture
CeMer Pivot I� ation Boom �$40
Manufactured Home Park Lots �$25 I here ce ' that I inspected tlie electrical ir�smlleGan des�xibed herein ai the dates st�d:
Recreational Vehide Park Sites � $5 "�"" �'�
Se rate Bondin Ins ection �$20
S ial In 'on �$30 r Fbur �'�"`�"0H � �'�
S 'al In eclion � $.31 r Mile �"'� � � ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFFlCE USE ONLY
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Requ te• Rough-in Inspection Required? ❑ Yes Inspection Other Than R 9h-In: dy Now � Will Call
You must cetl the inspector when readyl Date Ready: �
I certi(y ihat I am the�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereb request inspecfion of the electrical work at:
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Jqb A ress (Street, Box, or Route No.) Ciiy Zip Code
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Section Township Range Fire No. Coun
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Power Supplier Address
Electrical oMracror / Com� � �� � Contracroj License Number Master License Number
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Mai�ing A ess (Contrador, Company or OwneLr Perfortning I tatlon)
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Authorized Sig re (Co ; Company or Owner Pe rming Installation) Phon
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EB-OOOOtA-13 7/1/2000 BOAHD OF ELECTAICtTY COPY INSTRUCTIONS ON BACK OF YELLOW COPY