P - 76461REQUEST FOR ELECTRICAL INSPECTION
1� 7 8 7� 9 2 0 6 Minnesota Board of Electricity r
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 ���.
(651)642-0800TTY/MRS 1-800-627-3529 x�ww.electricity.state.mn.us
Describe -using the back of the ukite copy if nec�,s_,s�ary.:,the Wq�C,cOv,e�c�by,t�' ��que�t ;. r-., ;;,-;-.� ;
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GENERAL FEES Outdoor Lighting Standard @$1
SERVICES 1 POWER SUPPLIES Traffic Signai Standard @$5
0 to 400 Ampere $25 Supplemental Fee @$20
401 to 800 Am ere $50 Transformers u to 10 KVA $10
Rbove 800 Am re $75 Transformers over 10 KVA $ 20
CtRCUITS I FEEDERS Transformer I Power Su I for Si ns I Outline Li htin $5
0 to 200 Am re $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUiTS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Tri s $20
Each S stem Device or Apparatus @$.50 Investigative Fee
ADDITIONS TO THE GENERAL FEES Reinspection Fee $20
MULTIFAMILY DWELLINGS PER UNIT TOTAL FEE ;:}:i„`._?�?
3 to 12 Units �$50 Per Unit (minimum total fee is $20)
FEES
Boom a
ark Lots
I hereby certiry that I inspected �he electncal installation descnbed herein on ihe dates stated:
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eCial Inspection @$.31 per Mile I I
IPiSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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�, vate: I Rou h-in Ins ection Re uired? ❑Yes ���
g p q No 'i Inspection Other Than Rough-In: Ready Now Will Call .
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I I You must call the inspector when ready! I Date Ready: .
I certify that I am the �`] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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Jab Site Sfrse[t� Address ; City 1= '-� .r �. �_ .;• ��,� ::� c� �.1--,.:
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I Township - j Section i Range ;, Fire No. i County
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i OwnerlOccupant Name Please Provide Two (2) Phone Numbers In�
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��, Electncal Utilit Electrical Utility Address
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�, Con[factor / Company Name �. Contractor License Number Master Electrician or Po�
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I Matling Address.(Contracfor� Company or Owner Performin� Installa6on�
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, qµthoriznd S� nature (Contractor or Owner Performing Installation) Please Provide Two (2) Phone Numbers In
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