P - 78438�—..— - -- �
REQUEST FOR ELECTRICAL INSPECTION
1��f� �- 0 7 5� Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-OBQO TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
❑ NEW .fl�MODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
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�b e��c,�sdn � S� — � �7�I��S
JICES I POWER
0 to 400 Amcere
KVA
v�o cw r+ni ie �a �• v ONE 8� TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes ihe Service andlor Power Suppiy up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Cireuits and Two Inspection Trips Each Dwelling Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins tion Tri $20
Each S stem Device or ratus $.50 Invesfi ative Fee
ADDITIONS TO THE GENERAL FEES Reins tion Fee $20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE �
3 to 12 Units @$50 Per Unit (minimum total fee is $20) �
E2Ch Addi6onel Unit �$25 rH�s a� Foa uarECroa usE orar
I hereby cerUty tl�at I inspected the electrical insfallation desaibed herein on tlie dates sfated:
LighGng Retrofit
Center Pivot Irrii
�. ��.� ��..� �.+�u�+� �vn mr�r oc vRUe�ctu u�s�:VNNeG 1 CD IF NOT G�MPLETED WITHIN 12 MONTHS
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IIIII IIIII IIIII IIIII IIIII Ilill IIIINIIII N� �� rc�� �
1 5 3 1 0 7 5 8 �
Reyura� uace: Rough-in Inspection Required? ❑ Yes �NO Inspection Other Than Rough-In: ❑Ready Now II Call
!��"` 3'�3 You must call the inspeda when ready! Dale Ready: �
I certify that I am ttier �'LICENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Address (Strcet, Box. w Raute No.) CiH Zip Code
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..U�urn;ua ucense numoer M8S[8f GCCU1C18f1 Of
l.:ake. MN 55�04 � �UI��i6 u�,�nh,m�
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