P - 76104Q REQUEST FOR ELECTRICAL INSPECTION
1�� v�- 0 5 4 4� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.slate.mn.us
Dest�e -using the back of_the white copy'rf ne����,e'���y���:t; S S� T 1'rH
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ti GENERAL FEES Outdoor Lighting Standard @$1
SERVICES I POWER SUPPLIES Traffic Siqnal Standard Ca� $5
MdfA�IUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
tn 12 Units na $5D Per Unit
Hour
FEES
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ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Addi6onal Ins ction Tri $20
Investigative Fee
Reins 'on Fee @ $20
TOTAL FEE a� o.
(minimum total fee is $20)
THIS AREA FOP MSPECTOR USE ONIV
I hereby cartify that I inspected Ne eiectrical installaation descMb� herein on the dat�
TH#S FN$TALLATIO�I MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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�� Rough-fn Inspectlon Required7 ❑Ye �]No Inspectlon OtherThan Rough-In: ❑eReady Now ❑Will CaII
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You must call the inspector when readyl Date Ready:
I cErtify tl�af I am the [�J LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
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Tommship Section Range Fire No. Counry
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QwnedQccupant Neme Please Provide Tvro (2) Phone Numbers Including Area Code
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Electricel UtiNty Electrical Utllity Address
XCEL EhIEFiGY
Conbadnr / Company Name Contractor License Number Master Electrician or Pawer Limited Techniclan
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MaUing Atldress (C9ntractor, Company or Owner Perfortning Installatlon)
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AYthpriZid S �ature (Contractor or Owner Perfortning Installation) Please Provide Two (2) Phone Numbers Includirtg Area Code
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IN4rRlfCT1[Nd9 O!1 BACK OF YELLOW COPV BnARn C7F ELE('TRICITV COPV E&00001A-15 8.1. 2004