P - 76575REQUEST FOR ELECTRICAL INSPECTION
1-781-919 4 y .,��
❑ Minnesota Board of Etectricit �r-
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104 �
(651) 642-0800 TTY/MRS 1-800-627-3529 ti iti•iv.electriciry.slate.mn.us
Descnbe -using ihe back of the white copy if necessa the work wvered by this re uest
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GENERAL FEES Outdoor Li hting Standard @$1
SERVICES I POWER SUPPLIES Traffic Signal Standard @$5
0 to 400 Ampere $25 Supplemental Fee @$20
401 to 800 Am ere $50 Transformers u to 10 KVA $10
Above 800 Am re $75 Transformers over 10 KVA $ 20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li htin $5
0 to Z00 Am ere $5 E' � ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere $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 ction Tri s $20
Each System Device or Apparatus na $.50 Investioative Fee
Additional Unit @
li�hting Retroft @ $.25 per Fixture
Center Pivot irriqation Boom (� $4C
TOTALFEE `�+�`i
total fee is $201
that I inspected the electrical installation descnbed herein on the dates stated:
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Spedal Inspection @$30 per Hour t'"Ntp1qtlqNpONtp DATE
, Special Inspection @ $.31 per Mile
IIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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�a�e. Rough-in Inspection Required? ❑ Yes J�] No �I Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
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1 i L ... b You must call the inspector when ready! ���. Date Ready:
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I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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P 9 I Fire No. I County
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Ownqer/Occupant Name ��
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Please Provide Two (2) Phone Numbers
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'� tlecfncal Uttlirty� t�� y 'i Electrical Utility Address
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� Coniractor / Company Namet � �� Contractor License Number Master Electrician or
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MaiNng Address (Contractor, Company or Owner Pertorming Installation)
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��� Authorized Si nature (Contractor or Owner Performing Installation) � -! Please Provide Two (2) Phone Number.
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