P - 78011REQUEST FOR ELECTRICAL INSPECTION
1� 5 5 0�� o� � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Sairrt Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.e[ectricity.state.mn.us
NEW O REMODEL ❑ ADDITION ❑ REPAIR Describe -using e bx ihe white copy 'rf necessary - th� �is t:
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GENERAL FEES Outdoor Lighting Standard �$1
0 to 400 Am ere $25
401 to 800 Am ere $50
Above 800 Am ere E75
CIRCUITS I FEEDERS
0 to 200 Am re$5
Above 200 Am e $10
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or ratus 3.50
ADDITIONS TO THE GENERAL
Each
FEES
Su lemental Fee $20
Transfortners up to 10 KVA @$70
Trans(ortners over 10 KVA E 20
Transfortner I Power Su I for Si ns I Outline Li h6n $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
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(minimum total fee is $20) Q ' �
TH45AREAFp2RbPECTpiUSEdNLY
I hereby cerMy Mai I inspec0ed the elechical installa6on deuribed herein on the d�es stated:
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Special Inspection � 5.31 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 RougMn: y Now � VYfll Call
—/ 1�' 6,3 You must call the inspector when ready! Date Ready:
I certify that I am ttie LICENSED CONTRACTOR ❑CONIPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Address (StreeL Box. a Route No.) City Zip Code
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ON BACK OF YE BOARD OF ELECTRICIIY CAPV EB•00001M11 8.1. 2002