P - 79687REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board ot Electrici =�
1� 19 7- 8 4 6 �P �° 1821 University Avenue Suite S- 28, Saint Paul, Minnesota 55104 �
�„' (651) 642-0800 TTY/MRS 1-800-6273529
www.electricity.state.mn.us �� �
Identify the work covered by this request:
❑ NEW ❑ REMODEL ❑ ADDITION �REPAIR
GENERAL FEES Outdoor Li htin Standard (� $1
RVICES / POWER SUPPLIES Traffic Si nal Standard �$5
Am re �$25 y Su lemental Fee �$20
401 to S00 Am re �$50 Transformers u to 10 KVA �$10
Above 800 Am ere �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li htln �$5
0 to 200 Am ere �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere �$10 Includes the Service and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling UnH �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Trips �$20
Each S stem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ection Fee f� $20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units �$5o Per Unft (minimum total fee is $20) }�
Each Additional Unit � $25 '�"'"�"�TO� °� °NLY
OTHER ADDITIONAL FEES �1�� � � ��� �� ' ��
� hti Retrofit � $.25 er Fixture � �
Center Pivot Irri atlon Boom �$40 .
Manufactured Home Park LOts (� $25 I hereby certif(y that I inspected the electrical in�allatlon desaibed herein on the dates stated:
Recreational Vehicle Park Sites �$5 R0U011N o"'�
Se arate Bondin Ins ion �$20
S ecial In ion �$30 er Hour �'"�''�10N °"T�
S ecial Ins ection �$.31 r Mile �� ��� `�' 2—
__._ THIS INSTALLATION MAY BE ORDERED DISCONNE__CTED IF NOT COMPL�TED___WITHIN 18 MONT� ____
FOR OFFICE USE ONLY
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Request Date: Rough-in Inspection Required7 ❑ Yes �No Inspecdon Other Than Rough-In: ❑ Ready Now � WIII Call
Z Q Z You must call the inspector when readyl Date Reatly:
I certiiy that I am the,'� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Address (Street, Box, or Route No.) Ciry Zip Code
6 3 35' P�'�e s� F��l l
Section Township Range Fire No. County
OccupaM Phone
o � 5 �i.���l/�'i'
Power Supplier j
V �J
Electrical CoMractor / Company Name Contrador License Number Master License Number
IQo c. .�� /'c �� r�°. C fFd33 6 3 �'4/�`( O
Mailing Address (Contractor, Company or Owner Performing Installation)
70( � S�` �v,� �l-�,.�.� �,.v SSY
Authorized Signature (Contractor, Compan er Performing Installation) Phone ,r� C�� ,��,� �
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763�- � L—
E&00007A-1 /200p � BOApD OF ELECTRICtiV COPY INSTHUCTIONS ON BACK OF VELLOW COVY