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P - 76440REQUEST FOR ELECTRICAL INSPECTION 2� O�F ���� 6 � 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.staJe.mn.us Describe -using the back of the white copy if necessary - the work covered by this request: „ q,,., j + �V�V� -/ GENER4L FEES Outdoor Li htin Standard $1 SERVICES I POWER SUPPLIES Traffic Sianal Standard an $5 Above 200 Am ere a$10 ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Each Svstem Device or Auoaratus Cd $.50 3 to 12 Units @$50 Per Unit Each Additional Unit @ $25 Transformers over 10 KVA $ 20 Transfortner I Power Supply for Signs I Outline Lighting @$5 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 TOTALFEE total fee is $201 n<.. a j- �>" OTHER ADDITIONAL FEES LI htin RetfofR @$.25 pef FiXtu�e I hereby cert'rfy that I inspected the electrical installation desaibed herein on the dates stated: Center Pivot Irtiga6on Boom $40 RWfiHIN op.� Manufactured Home Park Lots $25 Recreational Vehicle Park Sites $5 ��"s�ECnor, on.� Se arateBondin Ins ection $20 /L-�( — U� Special Inspection $30 r Hour �o�Aeor+oor+eo oA,� S ecial Inspection $.31 r Mile THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS -_ '— —___"___—_—'_-- _'_'�'_"'�"�'. 1h ,._ 4r .""___'–r'I." l.<.��"'___ ;� ' � � � f��ll II III II I� II III I III I III II (II II III � III I III! �� ` �% ,�y//�7 .` � 0 4 ], 9 6 (� 9 n/ ���j ���/ ! / l ! ( � ,i . � Date: Rough-in Inspection Required? ❑ Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call � a�l You must call the inspector when ready! Date Ready: I ce�tify that I am the 0 LICENSED CONTRACTOR ❑ COMPANY p OWNER and hereby request inspection of the electrical work at Job Site Street Address City O -- (o�'h. 5-�- 1U E �R,1 � Township Section Range Fire No. County /� ��� / � OwnedOccupant Name Please Provide Two (2) Phone Numbers Including Area Code on.atd J � �S o (?� �ea- � ( ) ElecVical Utility Eleckical Utility Address ,�m�Na� �� �Q ��/ ConVadar Lice��Number Master Electrician or r1. �� �� �� � License Number C.� l.i ( /-4f' Y \ ....� � �ti� or Owne� Pertortnf In don) �� �� I�� 6 er Perfo ing In ta tion) Please Provide Two (2) Phone Numbers I � (�sl)'�7�-o3aF� ( ) ov wnnon nr ri Grroinrv rnov