P - 78966/� REQUEST FOR ELECTRICAL INSPECTION
1���t �-19 2❑5 Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of ihe while copy if nec/essary - the work covered by this request:
�1�► $ T-t. ( l��d 'it9t�tG dv4r"i1 p5 � KC P�t O Q� ll d �d t2 (�
GENERAL FEES Outdoor Li htin Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Am re $25 Su lemental Fee $20
401 to B00 Am re $50 Transformers u to 10 KVA $10
Above 800 Am re $75 Transfortners over 10 KVA $ 20
CIRCUITS I FEEDERS Transfortner I Power Su I for Si ns / OuUine Li h6n $5
0 to 200 Am re $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Inctudes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALIN� Circuits and Two tnspection Trips Each Dwelling Unit @$80
CIRCUITS, C�RCUITS OF LESS THAN 50 VOLTS Additional Ins 6on Tri $20
Each S stem Device or A aratus $.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reinsoection Fee (� $20
to 12 Units @$50 Per Unit
ach Additional Unit @ $25
Fi#ure
I II(I � III I( I II I I II I I I I11 I I f I I I I I�I f( I II !I �I I II�
1644L925
TOTAL FEE I /�
(minimum total fee is $20) p'�,`s�
TMIS AREA FIXt INSPECTOR USE 011V
I hereby certify that I inspected the electrical installa6on described heren on the da�s staled:
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��� �� Rough-in Inspection Required? ❑ Yes Inspectipn pther Than Rough-In: �Ready Now Will Call
�� ��� � Y Vou must call the inspector wh� ready! pete Ready
I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request mspection of tl�e electrical work at: