P - 79819REQUEST FOR ELECTRICAL INSPECTION
�31 J 2 6 5 Minnesota Board of Electricity
� � 1821 University Avenue Suite S-i28, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 'a
` www.electriciry.state.mn.us 6y�.
Identify the work covered by this request: �
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Sta�dard �$5
0 to 400 Am re �$25 Su lemental Fce �$20
401 to 8� Am ere �$50 Transformers u to 10 KVA �$10
Above 800 Am re (� $75 Transfortners over 10 KVA �$20
CIRCUITS / FEEDERS Transfortner / Power Su I for Si ns / Outline Li htin �$5
0 to 200 Am re�$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 CircuiGS and Two Inspection Tri s Each Dwellin Unit �$80
CIRCUITS, CIRCUITS Of �ESS THAN 50 VOITS Additional {ns ion T� �$2U
Each S stem Device or aratus �$.50 Investi tive Fee
ADDITIONS TO THE GENERAL FEES Rein 'on Fee �$20
MULTIFAMILY DWELLINGS PER UN TOTAL FEE
3 to 12 units �$5o Per Unit (minimum total fee is $2
Each Additanal Unit �$25 wH ir�croa use a+�v
OTHER ADDITIONAL FEES ��,��z 2- Q 1-
L' htin Retro�t �$25 r Fixture
Center Pivot 1' ation Boom �$40
Manufactured Home Park Lots (�? $25 I hereby ce' that I inspected the electrical installatian described herein on the dates siated:
Recrea6onal Vehicle Park Sites � fl01�" �' °A7E
Se rate Bondin Ins ection �
S ecial Ins ection �$30 r Hour � "`�`''"�"0N °"'��1
S ecial In ion �$.31 r Mile '1�'G /
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFFlCE USE ONLY
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Req Date: Rough-in Inspection Required? ❑ Yes ❑ No Inspection Other Than Rough-I � ow ❑ Wtll Ca�l
�� v� 4� You must call the inspector when ready! Date Ready:
I certity that I am the�J2�NSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Ro .) . Z�p Code
7 f ,3�
Section Township Ra ge Fre No. Goun ����� ,
� , /l.(.6r� C��
Occupant Phone
57a � �G
P�� s��i�e�
Els�ifjqg{'�Cd�p�r f�E �FQ �, . Contractor License Number Master License Number
Authorized
EBd0001A-13
NW � (�Oo
,�mer Performing Installation)
or PeAortning lnstaNation)
BOApD OF ELECTRICITY COPY
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INSTRUCilONS ON BACK OF YELLOW CO�°