P - 76564p REQUEST FOR ELECTRICAL INSPECTION '�
1�� O�- 914 ❑5 Minnesota Board of Electricity �,�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �. ,
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity '
state. mn. us
[I1B peCK Of [f1B WI1rt0 COpy It f1C�,QS$�y - the �y,prk�qye�ep,by�i�s r q��st; ��„ �.� �, � H
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GENERAL FEES Outdoor Liahtino Standard
JICES / POWER SUPPLIES
0 to 400 Ampere (� $25
ZM, COMMUNICATION, REMOTE CONTROL, SI
UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus (� $.50
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
L' hting Retrofit @$25 per Fixture
Center Pivot Irrioation Boom (� $40
Traffic Signal Standard @ $5
Supplemental Fee @ $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I 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
Additional Ins ection Tri s $20
Investigative Fee
Reinspection Fee @ $20
TOTAL FEE L�.��
(minimum total fee is $20)
TXiS AREA FOR INSPECiOR USE ON�V
I hereby certify that I inspected the electrical installalion described herein on the dates stated:
Se arate Bondin Ins ction $20 - — o� ����(s
S cial Inspection $30 per Hour Ex"REO ^a� oa.e
Special Inspection @ $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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17819145
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�� Date: i Rough-in Inspection Required? ❑ Yes 7[] No Inspection Other Than Rough-In: ❑CReady Now ❑ Will Call
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�_ _ i You must call the inspector when ready! I Date Ready:
I certify that I am the Ll LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
,ioas�i s tnda�e� c'yF'F;I��LLY h1h1
151. ba NIi �JAY
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, OwnerlOccupant Name �Please Provide Two (2) Phone Numbers Including Area Code
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��, tiectncai uuury I Electrical Utility Address
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Contractor / Company Name -� ��. Contractor License Number ; Master Electrician or P
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Mailing Address (Contractor, Company or Owner Performing Installation)
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Authorized Si nature (Contractor or Owner Performing Installation) � Please Provide Two (2) Phone Numbers I
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INSTRUCTIONS ON BACK OF vFl I nW f`nav aneon n� ci �rroirirv �no..
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