P - 79589REQUEST FOR ELECTRICAL INSPECTION
�� �e Minnesota Board of Electricity ��
1�� 2 6� 9� 4 � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
: � °�°`�� (651) 642-OS00 TTY/MRS 1-800-627-3529
� %� www.electricity.state.mn.us ''�'
IdentiTy the work covered by this request: ,
❑ NEW ❑ REMODEL ADDITION ❑ REPAIR �r� 1 `� "'°� ��,�
G NERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am re �$25 Su temental 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 htln �$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 Dwelling Unit �$80
CIRCUITS, CfRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Tri s�$20
Each S stem Device or A ratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ection Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL PEE . �?�
3 to 12 Units �$50 Per Unft (minimum tota) fee is $20) o v
Each Additional Unit �$25 FOfl INSPECTOR liSE ONLV
OTHER ADDITIONAL FEES
Li htin Rehofit �$,25 r Fixture
Center Pivot Irri atlon Boom �$40
Manutactured Home Park Lots �$25 1 I hereby cert' that I inspected the electrical instapatbn described herein on the dates s�ed:
Recreational Vehicle Park Sites �$5 R�H IN ��
Se rate Bondin Ins ion �$20
S cial Ins ection �$30 r Hour F'""""S°ECn°" °"�
S cial Ins ection �$.31 r AMIe ' Z��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED F NOT COMPLETED WITHIN 1 MO_NTH�_ _
FOR OFFICE USE ONLY
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Request Date: Rough-in Inspection Required? ❑ Yes No Inspection Other Than Rough-In: ❑ Ready Now Will Ca�l
''"� — I� OZ You must call the inspectof when readyl - � Date Ready:
I certify that I am the LICENSED CO OMPANY ❑ OWNER and hereby request inspection of tl�e electrical work at:
Job Address (Street, Box, or Rou[e No.) City ZP �e
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Sectian Township Range Fire No. ounry
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Power Supplier Address
Elec[rical Contractor / Company Name CoMractor License Number Master License Number
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Mailing Address (Contractor, Company or Owner Pertortning Installation)
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Authorized Signature (Cont actor, Company r Owner Pertorming Installation) Phone
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E&00001A,13 � I�/1/�20�0 ' ��� BOARD OF ELECTAICffY COPY INSTRUCTIONS ON BACK OF YELLOW COPN