P - 78301REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity '"—"°`
1- 3 4 7- 3 5 4 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 - _
www.electricity.state.mn. us
IdeMify the work covered by this request:
❑ NEW REMODEL ❑ ADDITION ❑ REPAIR
GENERAL FEES
0 ro 400 Am re�$25
401 to 800 Am re �$50
Above 800 Am ere � $75
UITS / FEEDERS
0 to 200 Am re �$5
Above 200 Am re � $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALIN
CIRCUITS, CIFCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aratus �$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units �$50 Per Unit
Each Additional Unit � $25
OTHER ADDITIONAL FEES
L' htin ReVofit �$25 r Fixture
Center Pivot I' ation Boom �$40
Manufactured Home Park Lots � $25
Recreational Vehicle Park Sites � $5
Se arate Bondin Ins ion �$20
Soecial Insoection � $30 cer Hour
�-�8 �'l L-- e t�-�C 6V � r i(.
Outdoor li hGn Standard � $i
Traffic Si nal Standard � $5
Su lemental Fee � $20
Transfortners u to 10 KVA �$10
Transformers over 10 KVA � $20
Transformer / Power Su I for Si ns / Outline Li htln �$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
G Circuits and Two Inspection Trips Each Dwellin Unit �$80
Additional Insoection Trios � $20
roA
FOR OFFICE USE ONLY
i�iiii� iiiii ��i�� ii�il i�iii {�i�r i�i�i �i�ii i�ii i��i �^j�a �
�E 1 3 4 7 3 5 4 1 3E �''' �1��
Request Date: Rough-in Inspection Required? es ❑ No Inspection Other Trian Rough-In: ❑ Ready Now Will Call
�V � You must call the inspector when ready! 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 Rou[e No.) CRy Zip Code
c�Sh, ���n S�1- � F �=,r ,�11� � 5 ti 3 2
Section Township � Range _ Fire No. ounty
�� ��
Ph��� � �' ��� �
' p2, � �r
nse Number Master License
Fee �
total fee is
-�, �'3
�. � �� °^�
F NOT COMPLETED WITHIN 18 MONTHS
Occupant � � � t..
1\�i� iy�� it �. \ � [� t�
Power Suppli Address
�. C�s
Eleclrical Contractor / Company Name Contrai
� w � l`. `
Mailing Address (Contrador, Company or Owner Performing Installation)
�m�i
Ayk�er,�ed�ignature (Contrador, CQ71�pany or Owner Performing Installation)
BOARD OF ELECTRICITY COPY
Phone
��� ��' � U� ��
INSTRUCTIONS ON BACK OF YELLOW COPY