P - 79001G REQUEST FOR ELECTRICAL INSPECTION
�c �U � � - � 5 6 ❑2 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
❑ NEW ❑ ODEL DDITION ❑ REPAIR Describe using the ba k of e white copy if necessary - the work covered by this request:
/.
NERAL FEES Outdoor Li h6n Standard $1
SERVICES I POWER SUPPLIES Traific Si nal Standard $5
0 to 400 Am re $25 Su lemental Fee $20
401 to B00 Amcere [� $50 Transformers uo to 10 KVA na S10
Center
B00 Am re 575 Transformers over 10 KVA $ 20
FEEDERS Transiortner I Power Su for Si ns I Outline Li htin $5
i0 Am re $5 � ONE & TWO FAMILY DWELLINGS, EACH UNIT
200 Am re $10 Includes the Service andlor Power Supply up to 500 Amperes, All
IMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$8(1
CIRCUITS OF LESS THAN 50 VOLTS Additional Ins tion Tri s $20
iystem Device or Apparatus &d_ $.50 Inves6oative Fee
Unit
25 pef Fixture
i Boom�
Park Lots $
Park Sites �
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16510562
( TOTAL FE j I n� �[Yl
minimum total fee is $20 p� J v
THiS MEA Fqi V6PECTOP lISE OKY
I hereby cerAfy that I inspected the electrical insfall�on described haein on the da�s sfa�d:
I IF NOT COMPLETED WITHIN 72 MONTHS
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Requesl D Rpugh-in Inspection Required? ❑ Yes ❑ No Inspeclion Other Than Rough-In: Ready Now � Will Cetl
��(� You must call the inspecta when ready! Date Ready.
I certify Uiat I am the ICENSED CONTRACTOR ❑COMIPANY ❑ OWNER and hereby request �spection of the electrical work at:
Jab Site Address (Slreet 8w4 or Route�r�o .) Zip Code
+�d/1 ..�. / � l/. _. �a If' .( ' . _ . �r�� -*,
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or
0
�/ �.�/YLQ/CCc�
Please Provide Two (2) Phone ber(s
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License Number
5���.l�/�/1/�LS ����-���__�
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EB-0OOO1M14 8.1.2002