P - 82021REQUEST FOR ELECTRICAL INSPECTION - .f�f`
(� Minnesota Board of Electricity � �
1�,O V 0-114 �� 1821 University Avenue Suite S-128, Saint Pauf, Minnesota 55104
� (651) 642-0800 TTY/MRS 1-800-627-3529
www. electricity.state.mn. us
Identiiy the work covered by this request: ��COh II�G �G/`iiQ�� � yr i h Coh �'�%�t�l%�
❑ NEW ❑ REMODEL ❑ADDIT�ON REPAIR
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
4Q1 to 8� Am ere �$50 Transformers u to 10 KVA �$10
Above 800 Am ere �$75 Transformers over 10 KVA �$20
CiRCU1TS / FEEDERS Transformer / Power Su I for Si ns ! Oudine Li htin �$5
0 to 200 Amoere �$5 n ONE & TW� FAMILY DWELLINGS. EACH UNIT
)MMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
vstem Device or AuDaratus � $.50
OTHER ADDITIONAL FEES
Retrofit � $.25 oer Fixture
�
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Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellin Unit C� $8(
Additional Inspection Trips (� $20
� Investiaative Fee
thatl
(minimum total fee is
��R/�IGI
the electrical insfallabon described herein <
a
FOH OFFlCE USE ONLY
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Request D te: Rough-in Inspection fiequired? ❑ Yes No Inspection Other Than Rough-In: ❑ Ready Now 11 Call
��0 ����� you must call the inspector when ready! Date Ready:
I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNEfl and hereby request inspection of the electrical work ai
Job Address (Street, Box, or Route o.) ��y �P �
1 �O a� -�l0�5 ��� �6� � � �
Section Township Range Flre No. Countv
� Occupant
(CoMradbF, Company or (
.� � S in ^ 1//l I,�C r
EB-00001A-13
Phone
76�- -$m �
i� Y i�� os¢ �l' � 2
nse Number Master License
;�z�ycf I�AoI[;
Perfortning Installation)
V.�. .� a� I
r Performing Installation)
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BOAHD OF ELECTRICITY COPV
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�N37AUCT10N3 ON BACK OF YELLOW COPY