P - 78146(] REQUEST FOR ELECTRICAL INSPECTION
1—� 9 J— 2 9 1 � Minnesota Board of ElecUicity
1821 University Avenue Suite S-128, Sairrt Pa�, MinnesoTa 55104
� (651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
❑ NEW 0 REMODEL ❑ I��ON ❑ REPAIR 'be -using3p� of tl� white copy�nec - the work covered by ihis request
401 to 800 Am ere S50
Above 800 Am ere 575
CIRCUITS / FEEDERS
0 to 200 Am re $5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus � 5.50
Ufllf �%Q
� Boom $4(
Park Lots $
Park Sites
� tion $2�
� 830 cer Hour
' Outdoor Li h6n t5ndard E1
Traffic Si nal Standard E5
Su lemental Fee $20
Transfortners u to 10 KVA $10
Transformers over 10 KVA $ 20
Transfortner / Power Su I for Si ns / OuUine Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes lhe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Insoection Trios (� S20
TOTAL FEE I �
(minimum total fee is $20) p�D • S
� ,M5 ARE/� FIXi �115PE�10R USE Of�l. �
I hereby cer6y that I inspected the electrical installaEOn described herein on the dales sfated:
:�� �-c� �
cial Inspection � $.31 per Mile --
NSTALLATION MAY BE ORDERED DISC! CTED iF NOT COMPLEiEL :.`�i�4M..12 MONTHS
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15992910
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Request Date: Rough�n InspeCtion Required? ❑ Yes ❑ No Inspection Other Than Rough-In: Ready Now ❑ Wi11 Call
Vou must wll tF�e inspedor when ready! Date Ready:
I certify that I am the � ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of 1he electriral Nrork at::
Job Site Add (Stree r Route No.
Zip Code
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IN87RUC710NS
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pprer ndaress
Contracta Lk
:ECIRIG: IN�. �
� forming InstaAation)
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, ompany or Ow perfprtning Installatlon)
� �� BOARD OF ELECTRICT' COPV
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�ecmGan a
Number ,
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E&00001A-14 8.1.2002