P - 78191REQUEST FOR ELECTRICAL INSPECTION
1-� 4 5- 4 0 4 I�F I Minnesota Board of ElecUicity
�� 1821 University Ave�ue Suite S-128, SaiM Paul, Minnesota 55104.
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using Ne bac/k 1of the white copy'rf necessary - the work covered by this request:
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GENERAL FEES Outdoor Li htin Standard $1
SERVICES / POWER SUPPLIES TraRc Sianal Standard � SS . i /�
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or aratus E.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighting Rehofit @ $.25 per fixture
Center Pivot Irrigation Boom @ $40
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites O 35
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Su demental Fee $20 v
Transformers u to 10 KVA $10
Transfortners over 10 KVA $ 20
Transiormer / Power Su I for Si ns I OuUine Li h6n a5
ONE 8 TWO FAMILY DWELLINGS, EACN UNIT
Includes the Service andlor Power Suppty up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$BO
Addifional Inspection Trips @ $20
Investiaative Fee
TOTAL FEE �/ ,�
(minimum total fee is $20) 7� -
iH15 AREA FOR INSPECiqt USE OW v
I hereby certify that I inspecMd the ekttrical insfalla6on described herein on the da0es sf�ed:
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L� OATE
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Request Dale: Rough�n Inspection Required? es ❑ No Inspection Other Than Rough-In: ❑Ready Now ❑ Will Cal�
— j-�� You must call the inspecla when ready! Date Ready:
I certify that I am tt�e �UCENSED CONTRA�`I OR' ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Address (Street a Route No.) ' GtY Zip Code
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Please Provide Two (2) Phone Number(s
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License Number
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.wu,wvea re �wmraaor. Pany a Uwner Penorming InstallationT Phone (s)
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IN8 C710N8 ON BACK OF GOPY BOARD OF ELECTRICITV COPY E&00001M11 B.1. T002
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