P - 76401REQUEST FQ��E_�LE� T�RICAL INSPECTION �
1� 3 4 7- 4 9 0 Minnesota Board o�ctricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 =
www. electri ci ty. state. mn. us
IdentiTy the work covered by this request: ,� /
❑NEW EMODEL ❑ADDITION ❑REPAIR � C �� �''�� L �L�-1K�1 GPcrL�
GENERAL FEES Outdoor ' htin Standard �$1
SERVICES / POWER SUPPLIES Traific Si nal Standard �$5
0 to 400 Am re �$25 Su lemental Fee �$20
401 to 800 Am ere �$50 Transtormers u to 10 KVA �$10
Above 600 Am re �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su for Si ns / Outline Li htln �$5
0 to 200 Am re(� $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service andlor Power Suppty up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri �$20
Each S stem Device or ratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reinsnection Fee � S2o
3 to 12 Units �$50 Per Unit
Each Additional Unit � $25
OTHER ADDITIONAL FEES
Lighting Retrofit � $25 per Fixture
TOTAL FEE
total fee is $20) �� ^�'"
Center Pivot Irri ation Boom �$40 ���� ps
Manuf2CtU�d Hortl@ Patk LotS �$25 I hereby certify that I inspected the e rical installa6on described herein on the dates stated:
Recreational Vehicle Park Sites �$5 "01GH "' y� o��
S rate Bondin I �on �$20 –�–�— – a -as
S ecial Ins ection �$30 er Hour FlNAL INSffC110N p p,,
S'al In ion �$.31 r Mile � j�� F/4 +�CJ
_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPL .ED WI HIN.�i/�6�MON S
FOR OFFlCE USE ONLY `�
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Request Date: Rough-in Inspection Required? Yes ❑ No Inspection Other Than Rou h-In:
g ❑ Ready Now�Will Cali
You must call the inspector when ready! Date Ready:
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY OWNER and hereby request inspection of the electrical work at:
J�Address (SVeet, Box, or Route No.)�� Crty �� ; ('� 7rP C� �
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Section Township Range Fire No. County
OccupaM
/Y1c�CO�1�S SK2i rJ
Power Supplier Address
Name
I Mailing Address (Contrador, Company or Owner Performing Installation)
Phone
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Contractor License Number � Master License Number
w r iynai � raccor, compa u ner rp,prwmnglf tion) Phone �^ /
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EB-00001A-13 7/1/2000 BOAHD OF E�ECTRICITY COPY INSTRUCTIONS ON BACK OF YEILOW COPY
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. i . Min���,��f'`d: o���lectricity
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NOTICE TQ: ��sta��erotwring p� _
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� ManuFacturer I Supp�ier ot Eqiiq�nMnt .:
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The following items are. deviations from the accepted standards of construction at the above described premises.
Numbers after each item reference the applicable National Elec�rical Code sections.
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CORRECT T�IE NOTED DEFICIENCIES and: G� �` �
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[y' Notify the inspector for re-inspection before covering �'Z�.-� 7� �
❑ Re-Inspection will be made at the final inspection �`� -.-
❑ Sign and retum this form to the contract inspector when corrsctions have been completed,
but no later than
Contract Inspedor : � � / Signature oj InstaUer
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Address Date of Compliei�a :_
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- A copy of this report will become a permanent
re�epn�aHam�, F r�, record of this inspection-.�t the Board of
� �' ,� % `% � � � Electricity. Form E&00116-04 (6/99)
White � Installer Canary - Board of Electricity Pink -Are ,Repte ,tabve � Green - Ins or
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