P - 77156REQUEST FOR ELECTRICAL INSPECTION
1� 814 � 2 9 3� Minnesota Board of Electricity � �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
C�r(„��� 'Zi �- (651)642-0800TTY/MRS 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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GENERALFEES
SERVICES I POWER SUPPLIES
0 to 400 Ampere a$25
401 to 800 Am re $50
Above 800 Am ere $75
CIRCUITS I FEEDERS
0 to 200 Am re$5 r
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus $.50
ADDITIONS TO THE GENERAL FEES
fIFAMILY DWELLINGS (PE
3 to 12 Units @$50 Per Unit
Each Additional Unit lcD $25
Outdoor Li nting Standard @ $1
Traffic Si nal Standard $5
Supplemental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns I 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
total fee is $201
I herebv certiN that I insoected the electrical installafion desaibed herein on the dates stated:
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites $5 F� INSPECTION DHTE
Se arateBondin Ins ion $20 � � �2-2d'"�
S iallnS ecti0n $30pCtH0uf EXPIREDIa9WDONED on�
S cial Ins ion $.31 per Mile
THIS INSTAILATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rou h-in Ins ection R uired?
g p eq ❑Yes No Inspection Other Than Rough-In: ❑ Ready Now Will Call
�� �_�� You must call the inspector when ready! Date Ready:
I cerfrfy that I am the ,�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Sheet Address City
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Township Section Range Fire No. Counry
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Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
Qi� �i �e,�S $(�3)571'�$( if�1)S�a- �44�
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, Co�ar� o�O��ter Perf�r rLng In
I Authorized
ise number Mas[er Electrfpan or Power Limitetl l
^ / �/�� License Number
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Please Provide Two (2) Phone Numbers Induding Area
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