P - 78755. ° REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity �
1� 2 9 5- 5 6 0 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-0800 TTY/MRS 1-800-627-3529
www. electricity. state. mn. us
Identify the work covered by this request:
❑NEW ❑REMODEL ❑ADDITION EPAIR ���� �- -- J'— �`���
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard (� $5
0 to 400 Am re�$25 Su IemeMal Fee �$20
401 to 800 Am re �$50 Transfortners u to 10 KVA �$10
Above 800 Am re �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer! Power Su I for S' ns / Outline ' htin �$5
0 to 200 Am re �$5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re�$10 Ir�cludes ihe Service and/or Power Suppty up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelli Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS A�iitional Ins ion Tri �$20
Each S em Device or ratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins 'on Fee �$20
MULTIFAMILY DWELLINGS PER UNI ( TOTAL FEE ,S�
3 to t2 Units �$5o Per Unit minimum total fee is $20)
Each Additlonal UnR � $25 w"'"S°E�T°" "s� °'L�
OTHER ADDITIONAL FEES
L' hti Retrofit �$z5 er FbRure 3 0 3� 9
Center Pivot Irri tion Boom �$40
Manufactured Home Park Lots �$25 I hereby ceriify mat � inspec[ed me electrica� ins�apa6an described herein an tlie daEes smmd:
Recreatbnal Vehicle Park Sites �$5 101GH" °"'�
Se rate Bondi Ins ' n�$20
S 'al Ins 'on � $30 r Hour � "�"01 ,�
S ecial In ection �$.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED T COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY
I Illlil l4�il lllil lllli illi! iilll lilll lllll llil llll ,� �� 3 8��
�E 1 2 9 5 5 6 O 5* D� ��) p 7�,s�
'�E�
Request Date: Rough-in InspecUon Required? ❑ Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now wli Call
� You must call the inspector when readyl Date Ready:
I certity that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspeclion of ffie electrical work at:
Job Address (Sheet, Box, or Route No.) City Zp Code
� � �. `d� v����
Section Township Range Fire No. County
OccupaM Phone
� 1 Q�L �c.� w/
Power Supplier Address
LX�e�
EI rical CoMrador / ny Name CoMractor License Number Master License Number
� �e
ailing Address ( Mractor mpany r Owner P orming Instalfation)
�' /% � �e��U 1'% �"o
Autho ' Signature (Contr r mpa r Owner Pertortning Installation) Phone
?l�� �9S/7 �
EB-00001A-73 7/1 BOARD OF ELECTRICITY COPY . INSTAUC7mNS ON BACK OF YELLOW COPY