P - 78332REQUEST FOR ELECTRICAL INSPECTION
1 3 4 7 3 9 5 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 work covered by this request: j
C.Of�v••t''� tS�'VI U �O V(��t.�l'OVinC
�NEW EMODEL ❑ADDITION ❑REPAIR
GENERAL FEES Outdoor Li htin Standard �$1
RVICES / POWER SUPPLIES Traific Si nal Standard �$5
to 400 Am ere �$25 G Su lemental Fee �$20
401 to 800 Am re �$50 Trans(ortners u to 10 KVA �$10
Above 800 Am re �$75 Transformers over 10 KVA �$20
CIRCUITS I 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 Am re �$10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Tri s Each Dwellin Unft �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri s�$20
Each S stem Device or aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reinsoection Fee ��20
3 to 12 Units �$50 Per Unit
Each Additional Unit � $25
OTHER ADDITIONAL FEES
Lightlng Retrofrt � $25 per Fixture
Center Pivot Irrigation Boom � $40
Manufadured Home Park Lots � $2
Recreational Vehicle Park Sites (� $
I herebvi cerMV that I inspected the electrical
TOTAL FEE
total fee is $201
stated:
Se rate Bondm Ins on �$20
�al Ins � $30 r Hour "� "�QtON ` o^�
ial In 'on �$.31 r Mile � d'�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED I COMPLETED WITHIN 18 MONTHS
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
� 1+Z �' b 4 You must call the inspector when readyl Date Ready:
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY '� OWNER and hereby request inspection of the electrical work at:
Job Address (Street, Box, or Route No.) Ciry Zip Code
l�l 15 �c��lli.ac�ca. �c�vt 1 v-�a �Q S S 42 �
Section Township _ Ranpe Fire No. Countv /
Occupa�„^,1 M � L G A V V tl t� ( Phon� � 3 —�"� J� "� 3 G
Power Sup ier ! Addre
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Electrical nt a r/ Company Name Contractor license Number Master License Number
Mailing Address ( ntre r, ompany or Owner Perfortning Installation)
� Authorized Signature (Cor�ctor, Company or Owner
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EB-OOOOtA-13
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BOARD OF ELECTRICfTY COPY INSTRUCTIONS ON BACK OF YELLOW COPY