P - 78129[ REQUEST FOR ELECTRICAL INSPECTION
�� J��— 2 9 5❑7 Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Sairrt Paul, Minnesota 55104
(651) 642-OB00 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
�MEW ❑ REMODEL ❑ ADDITION ❑ REPAIR Desc�ribe�ing the back of the white cop1'rf necessary - the work covered by this request:
0 to 400 Ampere @ $25
401 to 800 Am ere S50
Above 800 Am ere $75
CIRCUITS I FEEDERS
0 to 200 Ampere @ $5
Above 200 Ampere �$10
ALARM, COMMUNICATION, REMOTE CONTROt
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units �,1$50 Pe� Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Uc�h6ng Retrofit @ $.25 per Fixtu2
Center Pivot irrigation Boom � a40 �'
Mariufactured Home Park Lots E25 t.
Recreational Vehicle Park Sites $5
arate Bondin Ins tion E20
Special Inspection � $30 cer Hour
�C�RC^17
� Tr�siormers up to 10 KVA @$10
� Transformers over 10 KVA �? $ 20
Transformer I Power Supply for Sipns / OuUine LighGnq $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Inciudes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips � $20
InvesfigaGve Fee
Reinscecfion Fee C� $20
(minimum total fee is $20) J �
THIS ARFA FOR INSPECTOft USE ONLV
I hereby certfy that I inspecEed the electrical insfalla5on described h�ein on the dates sUted:
''��
II�I �III (I�I IIIII II (II IIII� IIIII �� �� (�
15932957 ���26y
��� -C�p�'1 y aS�S �
Request e: Rough-in Inspection Required? ❑ Yes Inspection Other Than Rough-In: ❑Ready Now ❑ Will Call
'� p� You must call the inspector when ready! Date Ready: �
I ce' that I am tl►e �.ICENSED CONTRACTOR � COMPANY ❑ OWNER and hereby riequest inspection of the electrical work at::
i Z- � � ��CY���� �-v-� � � � (�1.�!t' �p �� 3 2
I P�"T
INSTRUC710NS ON BACK OF YELLOW COPY BOARD OF ELECTRICITY COPV
c �
mascer uecmaan a rrower i
License Number
� M�U
��i gqy i `
EB-Oa
�
8.1.2002