P - 78868REQUEST FOR ELECTRICAL INSPECTION
1��� 7- 311 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
Identify the wark covered by this request: f �T
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❑NEW f�REMODEL ❑ADDITION ❑RE�AI� � ° S�
400 Am ere � $25 '
l0 8IX1 Am ere �$50 d �
e 800 Ampere � $75
i/FEEDERS
200 Ampere � $5
e 200 Ampere � $10
:OMMUNICATION, REMOTE CO
i, CIRCUITS OF LESS THAN 50
System Device or Apparatus �
ADDITIONS TO THE GE�
u11LY DWELLINGS (PER UNIT�
7 Units � $5p per Unft
Additional Unit � $25
OTHER ADDITIONAL
ig Retrofd � $25 per Fixture
r Pivot Irtigation Boom � $40
actured Home Park Lots � $25
a6onal Vehicle Park Sites � $5
�te Bonding Inspection � $20
I rattic si nal Standard �$5
$u lemental Fee � $20
ransformers u to 10 KVA �$10
Transformers over 10 KVA � $20
Transfortner / Power Su for Si ns / Outline Li hti �$5
ONE & TWO FAMILY DWELLINGS, EACH UNR
Indudes the Service and/or Power Supply up to 500 Amperes, All
CircuiGs and Two Inspection Trips Each Dwelling Unit �$B(
Fee �
(minimum total fee is $20) �/•
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e, n. C!►a,�•�,a-1 �r �...� ocn..�L.�rt
�"o uz.Er . �'�+ �
it I inspected the electrical inshallation described herei� on y�e de�es s�atcd
� s-� .
ATION MAY BE ORDERED DISCONNE�TED IF NOT COMPLETED WITHIN 18 MONTHS
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FOR OFFICE USE ONLY — _ _ �
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Request Date: Rough-in Inspection Required7 ❑ Yes No Inspec[ion Other Than Rough-In: ❑ Ready Now Will Call
S�� �3 You must call the inspector when ready! Date Ready:
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY OWNER and hereby request inspection of the electrical work at:
Job Address (Street, 8ox, or Route No.) ���, �P �
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Section Township Range Fire No. County
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���M Phone
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Power Supplier a
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Elechical Contractor / Company Name
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Mailing Address (Contractor, Company or Owner Perf�
Authorized SignaNre (Cyntractor, C�wnp�y pr Owner
A
7/1/2000
License
Installation)
BOAqD OF ELEC7AICITy Cppy
Master
3�6,34'-�626 I
INSTqUCT1pNS ON BACK OF YELLOW COpY -