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Identity the work covered by this request:
❑NEW ❑REMODEL ❑ADDITION ❑REPAIR
GENERAL FEES
0 to 400 Ampere � $;
401 to 800 Amoere �
0 to 200 Amoere d
REQUEST FOR ELECTRICAL INSPECTION
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 �5 " '
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CIRCUITS OF LESS THAN 50 VOLTS
ystem Device or Apparatus � $.50
ADDITIONS TO THE GENERAL FEES
OTHER ADDITIONAL FEES
Lighting Retrofit � $25 per Fixture
CeMer Pivot Irrigation Boom (� $40
Manufactured Home Park Lots � $25
Recreational Vehicle Park Sites � $5
Outdoor Li htin Standard � $1
Traffic Signal Standard � $5
Su lemental Fee � $20
Transformers u to 10 KVA �$10
Trar�sformers over 10 KVA � $20
Transformer / Power Su I ior Si ns / Outline Li htin �$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service ancUor Power Suppty up to 500 Amperes, All
CircuRs and Two Inspection Trips Each Dwelling Unit �$8(
Additional Inscedion Trios � $20
Fee �
(minimum totai fee is
296��
on the detes stated:
Special Inspection � $.31 per Mile � �`,2 �f�—�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
_._-.—.�_— --- — — — — — -- — -- -- —
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FOR oFFlCE uSE oNl �
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Aequest Date: Roughtin Inspectlon Required? ❑ Yes No Inspeclion Ot1�er Than Rough-In: Ready Now Q Will Call
L%~ y�0 Z I You musi calt the inspector when ready! I Date Ready: }
1 certiiy that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
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Saction Township Range Flre No. County
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Occupant Phone
s'%e'.�GtPo K W ��'� r a w ?� 3 78` -1o.3�S-/
Power Supplier Address
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Electrical Contrac[or / Company Name Contractor Lic;ense Number Master License Number
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Mailing Address (Contractor, Company or Owner Performing InstallaTion)
87� _�ar'? t!� � e N�1 2i�� . IYJw . j's"3��'
Auth� Si+�oMracror, Company or Owner Pertortning Installatlon) Phone
763-�sG-G o �o
E&OOOOtA-13 7/1/2(100 BOAHD OF ELECTIi1CRV COPY IN87AUCTIONS ON BACK OF YELLOW COPY