P - 77561REQUEST FOR ELECTRICAL JNSPFrTION
�� � � � � � Minnesota Board of Electricity
� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
- (651) 642-OS00 TTY/MRS 1-500-627-3529 ~' _
www.electricity.state.mn.us p��S�-�/��3
Identify the work covered by this request:
❑ NEW ❑ REMODEL ❑ ADDITION EPAIR C GL /�I � � T � "� / ' C�P� " C`v
GENERAL FEES Outdoor Li hG Starbard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard (� $5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10
Above 800 Am re �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transfortner / Power Su I for Si ns I Outline Li htin �$5
0 to 200 Am re �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re�$10 Includes the Service andlor Power Supply up io 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit �$80
CIRCU�TS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri s�$20
Each S stem Device or ratus �$.50 Investi live Fee
ADDITIONS TO THE GENERAL fEES Reins 'on Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units �$5o Per Unit (minimum total fee is $20) �
EaCh Addifi01131 U�It �$25 Fa+ ira�cra� use a+�v
OTHER ADDITIONAL FEES Zi � �
Li htin Retrofit �$25 r Fixture
Center Pivot Irri tion Boom �$40
Manufactured Home Park Lots �$25 � hereby ce uiat I inspected the electdcal installauon described herein on the dates stated:
Recreational Vehicie Park Sites � $5 �"" °A1E
rate Bondin Ins 'on � $20
S ial Ins ion �$30 er Hour Fl� I��C�� Dp�
S ial In 'on �$.31 r Mile � �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN yaMONTHS
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FOR OFFICE USE ONLY
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Request Date: Rough-in Inspection Required? ❑ Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now Will Call
�� �- �� You must call the inspector when readyl Date Ready:
I ceRify that I am the'�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (SVeet, Box, or Route No.) City Z�P �de
� C30 S r�Ci/t �' ! V� �lt S`.� 3 C.
Section Township Range Fire No. oun
3 � 24 �►�.oiC�
Occupant
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P� uoolier Address
Mailing Address (Conhador, Company or
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Authorized ig ture (Contractor, Compa�
EB-00001A-73 7/1ML000
Phone
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Contractor License Number Master License Number
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istallation)
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ing Installati ) Phone
c�3 �75�'"—S� 6v
BOARD OF ELECTRICRV COPY INSTRUC710NS ON BACK OF YELLOW COPY