P - 78059REQUEST FOR ELECTRICAL INSPECTION
�1 �� ��-13 5❑9 Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-0800T'fY/MRS 1-800-627-3529 www.elec[ricity.state.mn.us
❑ NEW O REMODEL ❑ ADDI ❑ R AIR Describe - ing the back of the white copy if necessary - the work covered by this request:
GENERAL FEES Outdoor Li htin Standard $1
SERVICES I POWER SUPPLIES Traftic Si nal Standard E5
0 to 400 Am ere $25 Suoolemental Fee B$20
401 to B00 Am ere E50
Above 800 Am re $75
CIRCUITS I FEEDERS
0 to 200 Am re $5 ,,.E
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
C�RCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or aratus $.50
ADDITIONS TO THE GENERAL FEES
Each Additional Unit
OT
LighGng ReVofit @ $
Center Pivot IrrigaBo
� Transiortner / Power SuDP�Y for Signs I OuUine Lighting @$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
CircuiGs and Two Inspection Trips Each Dwelling Unit �$80
TOTAL FEE � •
(minimum total fee is $20) p� �
THIS MEA FOR INSPECTOR USE ONLY
I hereby certify that I inspected the electrical inslaila6on described herein on the dales sfated:
FEES rr�/- l -/° - ` �(
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S ialins lion $30 r Hour `^""`"'"""'""`° """ I
Special Inspection @ $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Request Date: ^� Roughin Inspection Required? ❑ Yes ❑ No Inspection Other Than Rough-In: dy Now ❑ Will Call
�'(,�G..i You must calt the inspector when ready! Date Ready:
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby 2quest inspection of the electrical work at::
J�/U O(St x Route .� / r�l�� Zip Code
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Section Townshi {J�� ' No. Count
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Authorized Signature (COn , Company or Pertortning Installation)
IN87RUCTON8 ON BA K OF YE C BOARD OF ELECTRICITY CAPY
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ucer,se f�N,mber
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EB-00001A-14 8.1.2002