P - 80140REQUEST FOR ELECTRICAL INSPECTION
,, � �i� � � � 0 � �e 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
Identity the work covered by this requesT. i{ �_ h�/; . `. �( ���
❑ NEW ❑ REMODEL ❑ ADDITION R PAIR� , L'
GENERAL F ES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
f 0 to 400 Am ere �$25 Su plemental Fee �$20
401 to 800 Am ere �$50 Transformers u to 10 KVA �$10
Above 800 Am ere �$75 Transformers over 10 KVA �$20
CIACUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li htin �$5
^ 0 to 200 Am re �$5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 A re �$10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ir�s ion Tri �$20
Each S tem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins bn Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units �$50 Per Unft (mlNmUm tOt31 feC IS $2
EeCh Addltlonal Ufllt �$25 PoP IN5PECTON USE ONIY
OTHER ADDITIONAL FEES � �
Center Pivot I' aUon Boom �$40 I
Manufactured Home Park Lots �$25 I hereby certity that I inspected ihe electrical insTalla6on desciibed herein a� the � sMeted:
Recreational Vehicle Park Sites �$5 �01GH1N l—; i� � �_ °"e
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special Inspectio� � $.3t�r M�e — — /��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTI
FOR OPflCE USE ONLY
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I certify that I am the LICENSED CONTRACTOR ❑ C�MPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Add ss (Sheet, Box, or� No.) City Zip Code
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Section Township� Ran� Fire No. Coun
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Phone
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Power Su�e�A � p Addr � � � � ��� j� / � ��! ��
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Electrical Conhactor { Company Name CoMractor License
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Mailing Address (Contractor, Company or Owner Performing Installation)
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Author' ed Signature (Contr�ctor, Co ny or O�r�r Performing Installation)
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n�n000 BOMD OF ELECTHICRV COPY
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Phone
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INSTRUC710NS ON BACK OF YELLOW COPY