P - 77021REQUEST FOR ELECTRICAL INSPECTION
1 3 4 7� 5 5 0 Minnesota Board of Electriciry � ��1��.�aygb �
� tif 1821 University Avenue Suite S-128, Sain Paul, innesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529
www. electrici ty. state. mn. us
Identity the work covered by this request:
❑ NEW ❑ REMODEL ADDITION ❑ REPAIR � J�� �- � ^
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traific Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10 J
Above 800 Am re �$75 Transfortners over 10 KVA (� $20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns I Outline Li htin �$5
0 to 200 Am re f� $5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Ins ction Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional In bn Tri �$20
Each S stem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Rein ion Fee �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE s
3 to 12 Units � S5o Per Unif (minimum total fee is $20) J
Li htin ReVofit �$25 r Fixture
CeMer Pivot I' tion Boom �$40
Manufactured Home Park Lots (� $25 I hereby ce' that I inspected the electrical installatlon described herein on the dates stated:
Recrealional Vehide Park Sites � $5 '�"�"'" °"'�
Se rate Bondin In 'on � $20
S ecial Ins ection �$30 er Hour """""�`�0N /�}.
S' I In 'on �$.31 r Mile ���� v_
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFFlCE USE ONLY
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Request ate: Rough-in Inspection Required? ❑ Yes No Inspection Other Than Ro gh-In: Ready Now ❑ Will Call
�� /� � S You must call the inspector when ready! Date Ready: �� � O ��
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY �OWNER and hereby request inspection �of the electrical work at:
Job Address (Street, Box, or Route JV�.) �� �� Ctty �,�Lc_ y Zi�����
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Seciion Township Ran Fire No. County
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JQ�/V �V���� Phone �' ���—QllO G
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Power Supplier Address
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Electrical Contrector / Company Name Contractor License Number Master License Number
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Mailing A Contrector, Company or Owner Perfortning Installation)
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Auth ' nature Contrad , ompan or Owne Performing Installation) Phone
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EB-0000 3 7/1/2000 BOARD OF ELECTFi1CRY COPY INSTAUC710NS ON BACK OF YELLOW COPY