P - 77216REQUEST FOR ELECTRICAL INSPECTION ���'���
I �� 8'°#, �e � 3 7 5 � Minnesota Board of Electricity k �
1821 U' �itXAvenue Suite S-128, Saint Paul, Minnesota 55104 �. `
•
(651 0 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us e�i�
Describe -using the back of t e white copy if�ry - the w r by this:equest:
G
GENERAL FEES Outdoor Lighting Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere $25 Supplemental Fee @$20
401 to 800 Am ere $50 Transformers u to 10 KVA $10
Above 800 Am re $75 Transformers over 10 KVA $ 20
CUITS / FEEDERS Transformer / Power Su I for Si ns I Outline Li htin $5
0 to 200 Am ere $5 „¢.1t ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere $10 Includes the Service and/or Power Supply up to 500 Amperes, All
AIARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Tri s $20
Each S stem Device or Apparatus $.50 Investigative Fee
ADDITIONS TO THE GENERAL FEES Reins ction Fee $20
MULTIFAMILY DWELLINGS PER UNIT TOTAL FEE �D �O
3 to 12 units @$50 Per Unit (minimum total fee is $20) i
Each Additional Unil @ $25
OTHER ADDITIONAL FEES
Liqhtinq Retrofit (�a $.25 cer Fixture
I THIS
that I inspeded the electrical installation described herein on the dates stated:
DATE
m
C.t10� $30perHour EXPIRE�IABANDpNED DA1E I
ction @ $.31 per Mile
_LATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
i ���� �� ��I �� �I� �� ��I �� ��� �� ��� �) ��� �� ��� H� ��� -����
1 8 4 0 3 7 5 8 ��O� �
I certify that I am the ICENSEI
Job SRe treet ddres
own hip
/ upa t ame
�
lectrical Utility
CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of 4he electrical work at
�L�_ G�� �l . �/C1�/,e�,
Malling P�dress (Contractor, Compan Owner P rming Ins Ila'% t�yn) _ �/
iAI. % �a
� (// �� T
Autho i ignature d r or Owner Pertorm' Inst ation)
. /�% !
INSTRUCTIONS ON BACK OF YELLOW COPY BOARD OF ELECTRICITY COPY
Phone
ise Number Master Electrician or
/�%jyj� License Number
( / c/ �/
Numbers Including Area Code
� )
EB-00001A-15 A 1 7004