P - 78233REQUEST FOR ELECTRICAL INSPECTION
1'� /� Q���� 0 � Minnesota Board of ElecVicity -
•-f �� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
EW ❑ REMODEL ❑ ADDITION ❑ REPAIR Descnbe -using the back of the white copy 'rf necessary - the work covered by this request:
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GENERAL FEES Outdoor Li h6n Standard $1
SERVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Am re$25 Su lemental Fee $20
401 to 800 Am re $50 Transfortners u to 10 KVA $10
Above 800 Am re $75 Transformers over 10 KVA $ 20
CIRCUITS I FEEDERS Transfortner / Power Su I for Si ns / OuUine Li h6n $5
0 to 200 Am re $5 ONE & 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 Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins tion Tri s $20
Each S stem Device or aratus $.50 g�,,���,�-
ADDITIONS TO THE GENERAL FEES Reins ction Fee $20
MULTIFAMILY DWELLINGS PER UNIT TOTAL FEE .�
3 to 12 Units @$50 Per Unit (minimum total fee is $20)
E2Ch Addifi0fl21 Unif Q$25 THis nREn Foa iruaECTaa usE o'a. �
I hereby cer6y that I inspected Me electrical insUllation described herein on the dates stated:
OTHER ADDITIONAL FEES
htin Retrofit $.25 r Fixture
Center Pivot Irri ation Boom $40 R01GH1N �TE
Manufactured Home Park Lots $25
Recrea6onal Vehicle Park Sites $5 - F1N°' "'�PEGiO"' �*E
Se arate Bondin Ins fion $20 �d °��i e�
S ial Ins IOfI $3� f HOUf Erri�oinaesoor,EO pnTE
S ial Ins tion $.31 r Mile
THIS IN TALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Request Date: Rough-in Inspection Required. es ❑ No Inspection Other ThAn Rough-In eady Now ❑ Will Call
/ a — You must call the inspector when ready! Date Ready:
I certify that I am 1h�Q�CENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspec6on of the electrical work at::
Job Site Address (Street, Box. or Route No.) City Zip Code
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Sedion Township Ran e Fire No. County
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Owner/Occupant Name Please Provide Two (2) Phone Number(s) Induding Area Code
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Power Supplier Power Supplier Address
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ConVactor / Company Name Contracta License Number Master Electridan a Power Limited Technician
License I�mber
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Mailing Address (Contractor, Company or Owner Performing Instal a ion)
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AuN nature (ConVaCor, Company or Owner Perfortning Installation) ph (S)
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IN8TRUCTONS ON BAC OF VELLOW C BOARD OF ELEC7RICITV CAPV EB-OOOOtA-14 8.1. 2002