P - 79912REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
�� 2 6 8� V� 0 ��� tl 182� University Avenue Suite S-128, Saint Paul, Minnesota 55104
� �° (651) 642-0800 TTY/MRS 1-800-627-3529
www.electricity.state.mn.us
IdenUty the work cuvered 6y this request:
❑ NEW ❑ REMODEL ❑ ADD{TION REPAIfl
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Tra�c Si nal Standard �$5
� to 400 Am ere �$25 Su mental �ee @$20
401 to S00 Am re �$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 htin �$5
0 to 200 Am re �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 A re �$10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING CircuiGs and Two Inspection Trips EaCh Dwelli Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Addi�onal Ins ection Tri �$20
Each S stem Device or A aratus (� $.50 lnves6 Gve Fee
ADDITIONS TO THE GENERAL FEES Reins ection Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
�.,. ,� � �.,,.� r� e�� oe. ��.,�, Iminimum total fee is $20) �/�
Each Additional Unit � $25
OTHER ADDITIOP
Lighting Retrofit � $25 per Fixture
Center Pivot IrrigaUOn Boom � $4(
Manufactured Home Park Lots � $
Recreational Vehicle Park Sites �
- I I I herebvi certifv that I inspec[ed the electrical instaNaGOn described herein
SPeaaf Inspection �$ 31 per Mile � I��`� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF N COMPLETED WITHIN 18 MONTHS
FOR OFFICE !�E ONLY
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Request D e: Rough-in Inspection Required? ❑ Yes No Inspection O[her Than Rough-In: eady N C
� � 7 �`� You must call the inspector when ready! Date Ready:
I certi(y that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
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Occupant
Power S�
Address
Electrical Contractor / Company Name Goni
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Mailing Address (Contractor, Company or Owner Performing Installation)
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Autlrorize ig CoMractor, Com ny or r Perfortning Instaflation)
EB-00001A-13 7/7/2000 BOMD O�
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Phone
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License
License Number
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Pno�e
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Cppy UCTIONS ON BACK OF YELL COPY