P - 77625� � REQUEST FOR ELECTRICA� INSPECTION
1 3 4�517 � Minnesota Board of Electricity
� �■ 1821 Universiry Avenue Suite S•128, Saint Pau►, Minnesota 55104
c a+� sa2_oaoo TTY/MRS 1-800-627-3529
www.electricity.state.mn. us
Identity the work covered by this request: �� a`, � ��� � C �
❑ NEW ❑ REMODEL ❑ ADDITION EPAIR �
GENERAL FE Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES TraHic Si nal Standard (� $5
0 to 400 Am re �$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transiormers u to 10 KVA �$10
Above 8(10 Am re�$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transfortner / Power Su for Si ns / Outline Li htin �$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 CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additronal In bn Tri s�$20
Each S em Device or aratus �$.50 Investi atNe Fee
ADDITIONS TO THE GENERAL FEES Reins ection Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units �$5o Per Unit (minimum total fee is $20) � �
Each Additional Unil �$25 � i�c*oR usE a,�v
OTHER ADDITIONAL FEES
Li hti ReVoffi �$25 r Fixture
Center Pivot Irti ation Boom �$40
Manufactured Home Park Lots �$25 I hereby certily that I inspected tlie electrical insfallafbn described herein on ihe dates stated:
Recreational VehiGe Park Sites �$5 "01GH1N o��
Se arate Bondin Ins ion �$20
S ial In ion �$30 r Hour F*"""�0T101 — ��
S ial In ion �$.31 r Mile _---c`�'% ,�' Z-�' <-�
_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY �
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R�u:st Date: Rough-in Inspection Required? ❑ Yes o InspecUon O[her Than Rough-In: eady Now ❑ Will Call
Z� �� You must call the inspector when ready! Date Feady:
I certity that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Jab Address (Street, Box, or�g ute�No.) C Zip Code
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ized Sig re (Contractor, Co any o ner rfortning Installation) Phone
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IA-13 7/1/2000 BOAflD OF ELECTRICRY COPY INSTpU NS ON BACK OF VELLOW COPY