P - 76274Q � 62EQUEST FOR ELECTRICAL INSPECTION
1�� J—�`� - 5 4 7`�5 Minnesota Board of Electricity
1821 Univereity Avenue Suite S-128, Saint Paul, Minnesota 55104
� . (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
C3eat.�De -�irtg the back of the whfte copy'rf necessary - the work covered by this request:
E�CEL EhIC�;G;Y SAVEFi'� SWTTCH
7, COMMi1NIGATION, REMOTE CONTROL, SIGNALING
ITS, CIRGUITS OF LESS THAN 50 VOLTS
�ch System Device or Apparatus @ $.50
ADDITIONS TO THE GENERAL FEES
FAAd1LY DVIIELLINGS PER UNIT
to 12-units @ $50 Per Unit
ach Additiortal Unit @ $25
OTHER ADDITIONAL FEES
6ne Retrofit @ $.25 per Fixture
anter Pivot Irti ation Boom @$40
aru�factured Home Park Lots a$25
ecreational Vehicle Park Sites a$5
s�rarate Bonding Inspection (a� $20
aecial InspecUon p$30 aer Hour
Traffic
Fee
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Tvro Inspection Trips Each Dwelling Unit @$BO
Additional Inspection Trips @ $20
Investiaative Fee
TOTAL FEE ��o � i j
total fee is $201
electripl ins[allalion described herein on the dat� ste[ed:
�i �
TH1S IWSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
II�I IIII REC'D � i1N 14 200�
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Date: Rou h-in Ins ction Re uired? ❑ Yes
g pe q �[] No Inspection OtherThan Rough-In: �Ready Now ❑Will Call
I�i i�. �: / fj � You must call the inspector when readyl Date Ready:
I certify that I am the I�1 LICENSED CONTRACTOR ❑ COMPNNY ❑ OWNER and hereby request inspection of the electrical work at
Job Site StrBet Address City
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Tawnship Section Range Fire No. Cou ' L
Oamer/Occupant Alame Please Provide Two (2) Phone umbers Including Area Code
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Electricel Utility Electrical UUlity Address
�rEL EhaEfiC�
Cpr�ctor / Company Name Contractor License Number Master Electrician or Power Limited Technician
License Number
i-i�ri� ����T�.�c l•l��t���lFtta��o{'i cF� �J�J�'�J
' ing Address (Contractor, Company or Owner Perfortning I�stallation)
^34� T��iR.iiDhT�L �iDAI�g �AIi�f� F'AULq f�i�! 5511�
A�hor�ed Sienature (Contractor or Owner Performing Installation) Please Provide Twro (2) Phone Numbers Including Area Code
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