P - 77473REQUEST FOR ELECTRICAL INSPECTION �T�F
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� � Minnesota Board of Electricity S �„
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
` (651) 642-0800 TTYIMRS 1-800-627-3529 www.electricity.state.mn.us ��
Describe -using the back of the white copy if necessary - the work covered by this request:
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FEES
0 to 400
0 to 200 Am ere $5
Above 200 Ampere @$10
�M, COMMUNICATION, REMOTE CONTROL, SIGNALING
;UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Pe
Each Additional Unit @
Fixture
Manufactured Home
Recreational Vehicle
Outdoor Lighting Standard @ $t
Traffic Si nal Standard a$5
Supplemental Fee a $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transfortner / Power Su I for Si ns / Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Fee
TOTAL FEE I (,/�, � �
total fee is $201 7
that I inspeded tt�e NecVical installation described herein on the dates staled:
DATE
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Special lnspection $30 per Hour ="""`", "°"""'".`" - -
Soecial Inspectio� (� $ 31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS __
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Date: Rough-in Inspection Required? �Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now �Will Call
�/ L — L- f You must call the inspector when ready! Date Ready:
I certify that I am the I�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Si[e Street Address ��Y
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Township Section Range Fire No. Counly
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Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
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Contrador / Company Name
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Mailing Address (Contrador, Company or Owner Per
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Authorizal+Sianature (Contractor or Owner Perfom
Contractor License Number Master Electrician or Power Lim
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Installation)
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aliation) Please Prowde Two (2) Phone Numbers Including
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Rl1ARl1 nF FI FCTRICITV COPY EB-0000