P - 77238REQUEST FOR ELECTRICAL INSPECTION K��
1� O� J- 6 3 4 Minnesota Board of Electricity �- �
1821 Univereity Avenue Suite S-128, Saint Paul, Minnesota 35104
, �•'
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoor Liphting Standard an, $1
I SERVICES / POWER SUPPLIES
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aratus $.50
ADDITIONS TO THE GENERAL FEES
Each Additional Unit @
Center Pivot Irriaation Boom
Standard (�a
Transformers over 10 KVA $ 20
Transformer I Power Supply for Signs 1 Outline Lighting @$5
ONE 8 NVO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
total fee is $201 � �O ' S U-
I herebv certfi/ that I inspected Ne electrical installation described herein on the dates stated:
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i INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12_MONTHS ________�
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18156349
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Date: Rough-in Inspectian Required? ❑ Yes ❑ No Inspedion Other Than Rough-In: ❑ Ready No�ill Call
G[ ��� �� You must call the inspector when ready! Date Ready:
I certify that I am th LICENSED CONTRACTOR ❑ COMPANY O OWNER and hereby request inspection of the electrical work at:
Job Site SVeet Address City
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Township Section Range Fire No. County
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Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
/Pa�ocr� �'c.tG��ji1 (763) S'7/ a73�b � )
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Address (ConVactor, Company or Owner Per
ao ae c� �� 30
ized Signature (Cor�[ �tor or Owner Pgrforn
Conhactor License Number nnaster Eiecmaan or Power umae
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Please Provide Two (2) Phone Numbers Including Ai
(L!z) 79q—s"9is�( )
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