P - 76472REQUEST FOR ELECTRICAL INSPECTION �
1 787 897 6 "�:�
� � ❑ Minnesota Board of Electricity r �':
1827 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 x�x�x�.elecJricih�.state.mn.us
Debcnbe -using the back of the 46hite copy if ne¢ess3a�.: �the yaqr���e�r� by� ���yqu�,st, _� r.,� .y. _�. i^ ��
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0 to 400
401 to 8i
Above 8
.UITS 1 F
0 to 200
Above 2
tM, COh
111TS, C
Each Sv
GENERALFEES
ITS OF LESS THAN 50 VOLTS
Device or Apparatus @ $.50
�DITIONS TO THE GENERAL FEES
Additional Unit @
Boom
Outdoor Lighting Standard @ $1
Traffic Signal Standard @ $5
Supplemental Fee @ $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns / Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ection Tri s $20
Investigative Fee
Reinspection Fee $20
TOTALfEE �?+:a,
(minimum total fee is $201
I hereby
IL`F9�SYIPhI
I inspected the electrical installation descnbed herein on the dates stafed:
I ��' Q 7
S cial Ins tion @$.31 per Mile
Hl3 INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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, vate: �; Rou h-in Ins ection Re uired?
g p q ❑Yes 3[]No i Inspection OtherThan Rough-In: ['�Ready Now �Will Call
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I'�"'"'. �" " r' ��i You must call the inspector when ready! , Date Ready:
I cer6ly that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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OwnErlOccupant Name .. _- - . _ ��.... �-- .. _- . . �-- _ --- ----1._ . __... --
r ��� - !, Please Provide Two (2) Phone Numbers Including Area Code
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� Electrical UU6ty —�Electrical Utility Address
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' CoMractor ! Company Name ' Contractor License Number i Master Electrician or
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'' Mailing Address (Contrac'}t'or, LCompany or Owner Performing installatioqn)
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�/�uthori7xf S� nature Conhaclor or Owner Performin Installation , Please Provide Two (2) Pho
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