P - 79711REQUEST FOR ELECTRICAL INSPECTION
�° � � Minnesota Board of Electricity '�
����� ���� 3 � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529
www.electricity.state.mn.us
Identity the work covered by this request:
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR �/�/"laC/ / Wfiw
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10
Above S00 Am re �$75 Transformers over 10 KVA �$20
IRCUITS / FEEDERS Transiormer I Power Su I for Si ns / Outline Li htin �$5
0 to 200 Am ere �$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 and Two Inspection Trips Each Dwelli Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additlonal Ins ectan Tri s�$20
Each S stem Device or aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENER,4L FEES Rein ion Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to �2 Units �$50 Per Unit (minimum total fee is $20
Each Additional Unit �$25 FOF INSPEGTOR USE ONLY
OTHER ADDITIONAL FEES
Li htin Retrofit �$.25 er Focture
Center Pivot Irri ation Boom �$40
Manufactured Home Park Lots �$25 I hereby ce ' tliat I in ed a�e e�rical i�wuon described herein an me da[es siared:
Recreational Vehicle Park Skes � fl01�' W °ATE
Se arete Bondin Ins 'on � $
S ecial Ins ection �$30 r Hour '"��"0N °ATE
�
S ecial Ins ection �$.31 r MNe —�' � Z'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFflCE USE ONLY
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Requ Da : Rough-in Inspection Fiequired? ❑ Yes Inspection Other Than ough-I � Now ❑ Will Call
You must call the inspector when reatly! Date f;eady: .,2 �
I ce�ify that i am th ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and h reby request inspecfion of the electrical v�rork at
Job ddress (Street x, oc Route No �� Ciry ` Zp Code
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Section Tow hip Range • Fire No. County
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ower Supplier Address
Electri ntractor / Company Name Mractor License Number Master License Number
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Mailing d�ess (Co tractor, Company or Owner Performing Installation)
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Authorizetl Sig ture (C ,�ompany or Own r Pe mg Installation) Phon�� �� /�
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EB-00001A-13 7/t/2000 � BOAflD OF ELECTRICf1Y COPY INS'TFIUC710N3 ON BACK OF YELLOW COPY