P - 81996„ REQUEST FOR ELECTRICAL WSPECTION
Minnesota Board of Electricity �``
1� 13 7���� 'P � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� �� � (651) 642-0800 TTYfMRS 1-806-627-3529
www.electricity.state.mn.us '� '
Identity the work covered by this request: ���Q � f�-12 Q�/
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR G<
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si 1 Startdard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am ere �$50 Transformers u to 10 KVA �$10
A6ove 800 Am re �$75 Transtormers over i0 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su i for Si ns ! Outline Li htin �$5
0 to 200 Am re �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere �$10 Includes the Service and/or Power Suppty up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits arnJ Two Inspection Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri �$20
Each S stem Device or A aratus �$.50 Investi ative Fee
ADDITiONS TO THE GENERAL FEES Reins 'on Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE �.p ,SO
3 to 12 Units �$50 Per Unit (minimum total fee is $20)
Each Additional Unit (�? $25 f-0H 11SPE0T0” "� °�y
OTHER ADDITIOPfAL FEES �(/� ? ?1 o'L °
Li htin Retrofit �$25 r Fixture
Center Pivot Irri ation Boom �$40
Manufactured Home Park Lots �$25 I hereby certity that I inspected the eledrical instaNallon described herein on the dates steoed:
Recreational Vehicle Park Sites � "' � 10�" W o"'�
Seoarate Bondina Insoection � $
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT_COMPLETED WITHIN 18 MONTH5 __ _
FOR OFFICE USE ONLY
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Request Date: Rough-in Inspection Required? ❑ Yes No InspacHon Other Than Rough-1n: Ready Now WIN Cal{
7��� � You must call tha inspector when readyl Date Ready:
f certiiy that I am the (�{ LICENSED CON7RACTOR ❑ COMPANY ❑ OWNER and hereby request inspectlon of the electrical work at
Job Address (Street, Box, or Route No.) Ciry � �P �
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Section Township Range Fire No. Counry
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Occupant Phone
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Power Supplier Address
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Electrical Co�trador ! Company Name Crnrtrador License Number Masler License Number
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Mailing Address (Contradar, Company or Owner Perfortning Installation)
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Authorized Signature (Contractor, Company or Owner Perfortning InstaUa6an) Phooe
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EB-0OOOtA-13 7/1/2000 . BOARD OF ELECI'pICITY COPY U�7AUCT10NS Wi BACK OF YELLOW COPY