P - 82018REQUEST FOR ELECTRICAL INSPECTiON
� 1 % ,� Minnesota Board of Electricity
i�.L � 1- 6 0 5 ���� 1821 University Avenue Suite S-128, Saint Pauf, Minnesota 55104
" ��� (651) 642-0800 TTYIMRS 1-800-6273529
, ,� '�,C1,' www.electricity.state.mn.us
Identity the work covered y this request:
❑NEW REMODEL ❑ADDITION ❑REPAIR �yJ C��'�"�-�� �,9��� ��/�� �S
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPUES Traffic Sianal Standard �$5
Above 800 Am ere (� $75
IRCUITS / FEEDERS
0 to 200 Am ere �$5
Above 200 Am ere � $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
TIFAMILY DWELL{NGS (PER UNI
3 to 12 Units �$50 Per Unit
Each Add'Rional Unii � $25
OTHER ADDITIC
Lighting Retrofit � $25 per Fixtun
Center Pivot Irrigation Boom � $4
Manufactured Home Park Lots �
Recreational Vehicle Park Sites �
Senarate Bondin9 Insoection � &
Transfortners over 10 KVA �
� Transformer / Power Supply for Signs / Outline Lighting �$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Tri s Each Dwellin Unit �$8(
AddRional Insoection Trins � $20
total fee is
C89i�
1���,'
FOR OFFICE USE ONLY
I ��I��� ����� �I��� �i��� ��Ill tl��� t���i ���� ���� " ' � -T.s3 � �p ('� rc�
�E 1 1 c 7 6 O 5��E `�/`j� �t4c7 ( t7
Request Date: Rough-in Inspection Required? ❑ Yes No Inspection Other Then Rough-In: ❑ Ready Now II Call
'�i� �V You must caH the inspectw when readyf Date Ready:
I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (SVeet, Box, or Rout No.) City Zip Code
� V� Y� i� � I C� ��.Q, �
Section Township Range Fire No. CouMy
D
����,.1m,tS�ln ��-�P,�,V1 P�Co3 -���-��,��
Power SGpplier Address
EleddcaL�c��6om��rva�eECT., �N�'i. Contractor License Numt
CSb.A �
i3562 t,:ENTRFiL Ad�. N.�•
Mailing Addre , ner Pertortning Installation)
Authorized Sign tractor, m or er P rming In tion)
EB-00001A-13 �OARD OF ELECIRICRY �PY
Master License Number
Phone
%l�3 �57 (� � L
nasrnuc�►wros on sncx oF veuow covv