P - 76573REQUEST FOR ELECTRICAL INSPECTION �
1� 7 8 1� 9 O 2 � Minnesota Board of Electricity �r ,�
1821 University Ave�ue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy if necessa the work covered by lhis re uest:
EXC�L Ei�iEF:GY ;iF'iV�f; � v SWITCH
GENERALFEES
SERVICES I POWER SUPPLIES
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Traffic Signal Standard
Supplemental Fee @ $
Transformers up to 10
Transformers over 10 F
ONE 8 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 Inspection Trips fa� $20
tach 5ystem Device or Apparatus @$.50 Investigative Fee
ADDITIONS TO THE GENERAL FEES Reins ection Fee $20
fIFAMILY DWELLINGS PER UNIT TOTAL FEE ?
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3 to t2 Units @$5o Per Unit (minimum total fee is $20)
E2Ch AddltlOf181 Unif @ $25 misnaeaFORiNSPecroRUSEOe�v
OTHER ADDITIONAL FEES
Lightin Retrofit @$.25 pBf Fixtu�e I hereby certiry that I inspected the electncal installation described herein on the dates stated:
Center Pivot Irri ation Boom @$40 ft00GH �" oATE
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites $5 F�Nn� �NSaecnoN oATE
Se arate Bondin Ins ction $20 L--------1_. _ o? . Z_c� �
S Cial InSp2Cti0n @$30 pBf HOU� exwaeo nenNOONeo onre
Special Inspection @ $.31 per Mile
5 INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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�, uaie: I Rou h-in Ins ection Re uired?
g p q ❑ Yes J❑ No Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
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_ I You must call the inspector when ready! _ Date Ready _
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I certify that I am the -L�] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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wnship Section '� Ra e Fire No. Count
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OwnerlOccupant Name � �T Please Provide Two (2) Phone Numbers I
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tfec[ncai uni¢y i tlectrical Utility Address
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, Conhactor / Company Name � Contractor License Number ' Master Electrician or Power Limited Techni�
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'��, Mailing Address (Contractor, Company or Owner Performing Installation) �� � � -
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Authorizad Signature (Contractor or Owner Performing Installation) � Please Provide Two (2) Phone Numbers Including Area Code
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INSTRUC710N5 ON BACK OF YELLOW COPY anaRn nF Fi FcTairirv rnPV �o ,.,.�,..,, .� e.