P - 77416REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity '"�
1 s 3 4 7- 5 3 7 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529
ww .electricity.state.mn.us
Identify the work covered by this request: G�� �/ �f k k��(„
❑ NEW ❑ REMODEL ❑ ADDITION EPAIR L ��� ��_
GENERAL FE Outdoor Li hfi Standard �$1
SERVICES / POWER SUPPLIES Treffic Si nal Standard �$5
0 to 400 Am ere �$25 Su IemeMal Fee �$20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10
Above 800 Am re �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transfortner / Power Su I for Si ns / Oulline ' hti �$5 '
0 to 200 Am re �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re�$10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTHOL, SIGNALING Circuits and Two Inspection Trips Each Dwelli Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri �$20
Each S em Device or aratus �$.50 Investi tive Fee
ADDITIONS TO THE GENERAL FEES Reins ion Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE 1 `
3 to 12 Units �$50 Per Unit (minimum total fee is $20) /� J
Each Additional Unit � $25 F0"'"��'°" "� °'A`"
OTHER ADDITIONAL FEES
Li htin Retrofit �$25 er Fixture
Center Pivot I' tion Boom �$40
ManUfaCtutEd Hom@ Pa�k LotS �$25 I hereby cerbfy that I inspected the electrical installaUon described herein on the dates stated:
Recreational Vehicle Park Sites �$5 101GHM �"�
S rate Bondin Ins ion �$20
S ial Ins 'on � $30 r Hour � "�QfON � �^�
S 'al In 'on � $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTE OT COMPLETED WITHIN 18 MONTHS
POR OFFlCE USE ONLY
I illlll IIIII illll Illli I!fl111li1 Illll Iilil i{II IIII
* 1 3 4 7 5 3"7 1 �4
R Dat Rough-in Inspection Required? ❑ Yes No Inspec�UOn Other Than Rough-In: eady Now ❑ Will Call
✓
6 You must call the inspector when ready! Date Ready:
I certity that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job re (Street Ba Route No.) City Zip Code
� �� s� - �� ���
Sec[ion ownship Range Fire No. County
�v a�/ �}�bl�i9
t �t r� c�` /�c e
PoWe� s��re� 1 ; �
a�
�EI rical Contractor / Co any N e
v� `v�-���� �
or
�
I�
E&OOOOtA-13
Address
0
Phone �� - �--7� 6 .3S
�. g �-
� D�'�r 1J> ✓ �
.� Contra or Lice� Number Master License Number
� �
istallatio �
� �� .�"3�/
ing I lation) Phone
�
BOAHD OF ELECTRICITY COPY INSTAUCTpNS ON BACK VELLOW COPY