P - 81686REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity '�
1� V b 2� O 2 8 ',��, 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
+ (651) 642-0800 TTY/MRS 1-800-627-3529
www.electricity.state.mn.us
Identity the work covered by this request ' ��,r�� N� �-��Y
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EW ❑ REMODEL ❑ ADDITION ❑ REPAIR
GENERAL FEES Outdoor Li Gn Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 . Su lemental Fee �$20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10
Above 800 Amoere �$75 Transformers over 10 KVA �$20
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device os A aratus �$.50
ADDITIONS TO THE GENERAL FEES
Each Additional Unit � $25
OTHER ADDITIONAL FEES
Lighting Retrofit � $25 per Fixture
Center Pivot Irri ation Boom �$
Manufactured Home Park Lots �
Recreational Vehicle Park Sites � $5
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Transformer I Power Su I for Si s I Outline Li hti �$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, AI�
Circuits and Two Inspection Trips Each Dwelling Unit �$8(
Addkional Insoection Trios � $20
einspection Fee (� $20
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total fee is $20) I�b' � �
Fat OFRCE USE ONLY
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' Request Date: Rough-in Inspection Required? ❑ Yes �'Rlo Inspection Other Than Rough-In: �I'Aeady Now Q Will Call
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a— �� �� You must call the inspector when readyl /" Date Ready:
I certi(y that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Route No.) Ciry Zip Code
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/ Company
� Mailing Address (Contractor, Company or
Phone
71p3-�3Sf- S
Contractor License Number Master
G�ren �36 P
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COPY INS7HUCTIOW3 ON BACK OF YELLOW COPY