P - 76613REQUEST FOR ELECTRICAL INSPECTION -���°�
1� O��� 3 9 8� Minnesota Board of Electricity �- ;�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
Describe -using the back ofithe white copy'rf necessary - the woric covered by this request:
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GENERAL FEES Outdoor Lightin Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Amcere C�a $25 Su�ulemental Fee an $20
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A paratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Unfts (�D $50 Per Unit
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Senice andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiqafive Fee
total fee is
I hereby certify that I inspected the electrical inslallation described herein on the dates stated: I
Center Pivot Im ation Boom $40 "�"*'"
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites $5 F �s�c"°" �
Se arate Bondin Ins ion $20 � —'�—"�
S ial Inspection $30 per Hour E%PIREOIABANDONEO
S ial Ins on $.31 per Mile
5 INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1
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Date: Rou h-in Ins
g pection Required? ❑ Yes �J Inspection Other Than Rough-In: � Ready Now�Yl�'ll Call
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11 � Q You must call the inspector when ready! Date Ready:
I certify that I am th ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical wo�k ai
Job Site SUeet Address City
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Township Section Ranae Fire No. CounN
Electrical Utilky E
Contractor / Company Name
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Mailing Address (ConVactor, Company or Owner Pe
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Autho ' igna (Contractor or Owner Perfortni
INS IONS ON BACK O CO
Please Provkfe Two (2) Phone Numbers InGuding Area Code
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License Number Master Electrician or Power Limited Technh
�� License Number
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Please Provide vo (2) Phone umbers Induding Area Code
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)PY EB-00001A-15 8.1.