P - 77560.�UEST FOR ELECTRICAL INSPECTION
/� %Q �nesota Board of Electricity ' "�
1� 3 4 7�`t 1 V y$21 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 =
www.electricity.state.mn.us
Identity the work c by this request:
❑NEW REMODEL ❑ADDITION fB'EiEPAIR
0 to 400 Am re �$�
401 to 800 Am re �
Above 800 Am ere �
CIRCUITS / FEEDERS
0 to 200 Am re �$!
Above 200 Ampere �
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aratus �$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units �$50 Per Unit
Each Addifional Unit � $25
OTHER ADDITIONAL FEES
Li htin Retrofit �$25 r Fixture
Center Pivot Irri ation Boom �$40
Manufactured Home Park lots � $25
Recrea6onal Vehide Park Sites � $5
Se rate Bondin In ion �$20
S ial I ' �$30 r Hour
Soecial Insoection � �.31 oer Mile
Outdoor Li htin Standard � $1
TraHic Si nal Standard � $5
Su lemental Fee � $20
Transfortners u to 10 KVA �$10
Transfortners over 10 KVA � $20
Transformer / Power Su I for Si ns / Outline Li htin �$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspeclion Trips Each Dwellin Unit �$8L
Additional Ins ection Tri s�$20
Investl ative Fee
Reinsoection Fee � $20
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total fee is $20 � '
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that I ins ected the electrical insfallalion described herein on the dates stated:
DRTE
� 18,„��
DATE
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY
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Request Date: Rough-in Inspec[ion Required? es ❑ No Inspection Other Than Rough-In: ❑ Ready Now ill Call
Q�_ u must call the inspector when ready! Date Ready:
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (Strcet, Box, or Route No.) City Zip Code
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Section Tawnship Range Fire No. unry
Occupent �
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Power Supplier
Electrical Contrador / Company Name
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Mailing Address (Contractor, Company
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E&00001A-13 7/1/2000
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Phone
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Address
Contrador License Number Master License Number
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or Owner Pertorming Installation)
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�any or Owner Perfortning stallation) ne
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BOARD OF ELECTRICRY COPY INS7AUCTIONS ON BACK OF YELLOW COPY