P - 77492(� REQUEST FOR ELECTRICAL INSPECTION ��
2� 0 41 �`° �� C� � Minnesota Board of Electricity �-,
1821 UniversRy Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using t back of white co� if neces ry- the work covered by this request:
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GENERAL FEES Outdoor Liahtin St9 andard (�D $1
SERVICES / POWER SUPPLIES
0 to 400 Ampere $25
401 to 800 Am re $50
Above 800 Am ere $75
CI CUITS / FEEDERS
0 to 200 Am ere $5 �
ve 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units Co� $50 Per Unit
Center Pivot Irtigation Boom
Manufactured Home Park Lc
Special Inspection a$.31 er Mile
THIS INSTALLATION MAY I
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5landard '
Fee (� $20
Transformer I Power Su I for Si ns I Outline Li htin $5
ONE � iW0 FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspectlon Trips Each Dwelling Unit @$80
Additional Ins ion Tri s$20
Investi ative Fee
Reins tion Fee $20
TOTALFEE
(minimum total fee is $20) � � 1JZ1
THIS FREA FOR INSPECTOR USE ONLY
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I hereby cerGfy thal I inspec[ed ihe electrical installation desaibed herein on ihe dates stated:
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DISCONNECTED IF NOT COMPLETED WITF
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1°";�'� �'�� Rough-in Inspection Required? �❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call
IYou must call the inspector when readyl Date Ready:
I certi(y that I am the „�ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
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T���P Section Range Fire No. County
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Owner/Occupant Name [�� �? Please Provide Two (2) Phone Numbers Including Area Code
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Co r/CompanyName
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� iling Ad ss Contra�mp;
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Auth ' ed 'gnature (Contractor
INSTRUCTIONS ON BACK ELLOW
ElecUical Utility Address
CoMrador
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BOARD OF ELEC7RIC�TV COPv
Master Electrician or
License Number
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