P - 78420REQUEST FOR ELECTRICAL INSPECTION
�- 4 71-18 3� 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
��7 NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using the b�k of the white copy' necessary - the work covered by this request:
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GENERAL FEES Outdoor Li hti Standard $1
0 to 400 Ai
401 to 800
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS Of LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Each Addifionai Unit @ $25
I HII II II� II �I� II III �I II� �� II� �I II) II (II �� I�
14711832
Traffic Si nal Standard �$5
Su demental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns I Ouiline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Inciudes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
(minimum total fee is $20) � �
THIS ARFA Fpi IlEPECiIXi USE 0l8v
I hereby cer6y that I inspected the electric� insf�lation �scribed henl�on thgd� �
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Request Date: Rough-in Inspection Required? � Yes �b Inspedion Other Than Rough-In: ❑Ready Now ❑ N�I Call
�r. 1,^� You must call the inspector when ready! � Date Ready:
I certHy Uiat I am the �ICENSED CONTRACTOR ❑ COMPAI�Y ❑ OWNER and hereby request inspection of the electripl work at:
Job Site Addrass (Straet Box, or Route No.) � ZiP Code
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�wer Supplier Powet up er
rrtractor / Company Na
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gilmg Address (Ca�tractor Pany or Owner in Installation)
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dhoriiad9lanature (Contredor. CanDanv or Owna Perfortning Installatro
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oF rEUOw coPr eoato oF e�crnicm coPr
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Master Elecficien or
License Number
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E&OOOOtMt4 8.1.2002