P - 77437REQUEST FOR ELECTRICAL INSPECfION '�
1� 8 6��s 9� 2 � Minnesota Board of Electricity o{ Z2 o O�'j' �,� � s.
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104 �.
(�/'�'� �t�"� (651)642-0800TTY/MRS1-800-627-3529www.electricity.state.mn.us
Describe -using the back of the white copy 'rf necessary - the work covered by this request: �
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GENERAL FEES Outdoor Li htin Standard $1
SERVICES I POWER SUPPLIES i�-. Tratfic Si nal Standard a$5
Above 200 Am ere a$10
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus Ca� $.50
Unit @
Lighting Retrofrt @ $.25 per Fixture
Center Pivot Imqation Boom (�D $4(
Supplemental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns I Outline Li htin $5
ONE 8 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
Additional Ins ion Tri s$20
Investi ative Fee
Reins ection Fee $20
TOTAL FEE �a,..y
(minimum total fee is $20) —:«r
I hereby cer6y thal I inspected the electrical installation described herein on the dates stated: �
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Special Ins ion $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12
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18639625
Date: Rou h-in Ins ection Re uired?
g p q ❑ Yes ❑ No Inspedion Other Than Rough-In: ❑ Ready Now � Will Call
R`p� CJ/Q s You must call the inspector when ready! Date Ready:
I cert'rfy that I am the 0 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Street Address C�y
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Township Section ,1 Range Fire No. County
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OwnedOccupant Name Please Provide Two (2) Phone Numbers Including Area Code
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INSTRUCTIONS ON
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� License Number Master ElecVician or Power Limited
License Number
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3 Installation) Please Provid Two (2) Phone Numbers Including Area Code
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BOARD OF ELECTRICIN COPY FR-00001A_15 a � �ma