P - 80525REQUEST FOR ELECTRICAL INSPECTION
' n Minnesota Board of Electricity � ; —
�� 15 3� 1�'t �, � 821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
t (651) 642-OS00 TT�'(MRS i-800-627-3529
www.electricity.state.mn.us " '
Identify the work covered by this request: � � �,l� �i Y t5 �y p/O Q u/.y� �l Ct �7 E,' CJ � eLf%
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❑NEW ❑REMODEL ❑ADDITION PAIR �3� c��acu�r/ut������d�0�e� - r��.
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 . Q r Su lemental Fee �$20
401 to 800 Am ere �$50 Transformers u to 10 KVA �$10
Above 800 Am ere (� $75 Transfortners over 10 KVA �$20
CIRCUITS / FEEDERS Transfortner / Power Su I for Si ns / Outline Li htin �$5
0 to 200 Am re �$5 �y ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere �$10 Includes the Service and/or Power Supply up to 500 Amperes, AII
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Tri s�$20
Each S stem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ection Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to 12 Units �$50 Per Unif (minimum total fee is $20) 36
EBCh Addltlon0l Unit �$25 i0H INSPECTOB IISE ONLY
OTHER ADDITIONAL FEES
Li htin Retrofil �$25 r Pixture
Center Pivot Irri tion Boom �$40
Manufactured Home Park Lots �$25 I hereby cerrtily that I in tlre e�earica� i�utapae«i descr�ed nerein on aie dates stamd:
Recreational Vehicle Pa�C Sites � $5 "01GN1N °"'�
S rate Bondin Ins 'on � $20
S ial Ins 'on �$30 r Hour �"'` "�G10N G� '�
S ial Ins 'on � $.31 r Mile ! ` ' ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED OT COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY
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Request Date: Rough-in Inspection Required? ❑ Yes o Inspection O[her Than Rough-In: Ready Now ❑ Will Call
$,�! �� 6/ � You must call the inspector when ready! Date Ready: � 3 � � �
I certfy that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspeclion of the electr�al work at
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Job Address (Street, Box, or Route No.) Ciry � � e Tap Code
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Section Township Range Fire No. County
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Power Supplier Address
Electrical CoMractor / Company Name Contractor License Number Master License Number
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Mailing Address ontractor, Company or Owner Pe orming Installation)
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Au[ 'g ture (Contra or, Com or Own Perfortning Installation Phone
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EB 1 7/1/2000 BOAFID Of ELECTHICRY COPY IN37FiUCT10NS ON BACK OF YELLOW COPY