P - 79595' REQUEST FOR ELECTRICAL INSPECTION
/� Minnesota Board of Electricity ��
�- 2 21 �`t H H e v 1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104
' �a` � ��� (651) 642-OS00 TTY/M RS 1-800-627-3529
www.electricity.state.mn.us " '
Identify the work covered 6y this request: �� N��� R- l c.. _
❑ NEW ❑ REMODEL ❑ ADDITION REPAIR
GENERAL FE S
SERVICES / POWER SUPPLIES
0 to 400 Am re �$25
401 to S00 Am re �$50
Above 800 Am ere � $75
CIRCUITS / FEEDERS
0 to 200 Am ere �$5
Above 200 Am re � $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or aratus �$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units �$50 Per Unit
Each Additional Unit � $25 `
OTHER ADDITIONAL FEES
Li htin Retrofit �$25 r Fixture
Center Pivot Irri ation Boom �$40
Manufactured Home Park Lots �$25 i
Recreational Vehicle Park Sftes � $5 � `
S rete Bondin Ins 'on � $20
Soecial Insoection � $30 cer Fbur `
Outdoor Li htin Standard � $1
Traffic Si nal Siandard � $5
Su lemental 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 and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellin Unit �$8(
Additional Inspection Trips � $20
Investiaative Fee
total fee is
that I insoected the electrical insNallation described I�rein on Ihe dates
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FOR OFFICE USE ONLY
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Request te: Rough-in Inspeclion Required? ❑ Yes No Inspection Other Than Rough-In: Ready Now ��It Call
� f �'1i You must call the inspecta when ready! Date Ready:
I certity that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspectlon M the elecVical work at:
Job Address (Street, Box, or Route No.) City Zp Code
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Section Township Range Fire No. County
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Occupant Phone
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Power Supplier Address
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Elec[rlcal Gontractor / Company Name Contractor License Number Master License Number
,�Ts �c�c e/�-c> i y
Mailing Address (Contrador, Company or Owner Performing Instellation)
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Authorized Signature (Contrector, Com or Owner Performing In tion) Phone
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EB-00001 A-73 7/1/2000 BOMD OF ELECTRICRY COPY INSTRUC110N3 ON BACK OF YELLOW COPY