P - 77503Q REQUEST FOR ELECTRICAL INSPECTION �
1�� O�- 9 3 3 � Minnesota Board of Electricity ,'�e�'
❑ 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104 --
(651) 642-0800 TTY/MRS 1-800-627-3529 wwx�.electricity.s�ale.mn.us
peaCribe -usirfg the back of the whitg copy if ne�e,s�spf�3the y�o�IC�cqu�rf eQ,by ��f ��c�ue,st. ,_: c(� �;° i'��;
GENERAL FEES Outdoor Li htin Standard $1
SERVICES I POWER SUPPLIES Traffic Sianal Standard (� $5
0 to 400 Ampere $25
401 fo 800 Ampere @ $50
Above 800 Ampere @ $75
;UITS I FEEDERS
0 to 200 Ampere (� $5
Above 200 Ampere @$10 �
2M, COPAMUNICATION, REMOTE CONTROL, SIGNALING
UITS, CIRCUITS OF LESS THAN 50 VOLTS
�ach System Device or Apparatus @ $.50
ADDITIONS TO THE GENERAL FEES
flFAbtILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
U�htin� Retroft @ $.25 per Fixture
Center Pivot IrriQation Boom (a� $40 �
Supplemental Fee @ $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investigative Fee
Reinspection Fee @ $20
TOTAL FEE ;?ij,
(minimum total fee is $201
that I inspected the electrical installation described herein on the dates stated:
Se araate Bond' Ins tion $20 --�; ZG�O'�
S ial Inspection @$30 per Hour =XP1�``o ^"'''` '"E� oATE
Special IrSpection � �.31 per Mile
THIS IN3TALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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I""O� I Rou h-in Ins ection Re uired?
. , g p q ❑Yes :�]No IlnspectionOtherThanRough-In: [�:ReadyNow�WillCall
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�� �� You must call the inspector when ready! I Date Ready:
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I certify that I am the [� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
� Job SRe SVeet Address. .. . - .. - �- - - � City r� �-• �� E y � r c �•:
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wner/Occupant Name - - �
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'I Please Provide Two (2) Phone Numbers
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i Electricai UtiNty ! Electrical Utility Address -
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i Conhactor / Company Name � Contractor License Number Master Electncian or Power Limited Technician
�, ���i��� �.L.�,C:T^:.ti., i~i_�i1-�.����T!�..,.; L::^� iii'i��-;_? �LicenseNumber I
MaJing Address (Contractor Company or Owner Performing Installation) I � -� I
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. Autho[izpd Si nature (Contractor or Owner Performing Installation) � Please Provide Two (2) Phone Numbers Including Area Code
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INSTRUCTIOMS ON BACK OP YELLOW COPY BOARD OF ELECTRICITY COPY pR-nMmA-�5 a t �nna