P - 765741 7 81 916 O REQUEST FOR ELECTRICAL INSPECTION
� � Minnesota Board of Electricity �'���\ '
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �: ;
(651) 642-0800 TTY/MRS 1-800-627-3529 x�u•x�.electricrh�.state.mn.us -
Describe -using the back of the white copy if necessa the work covered by this re uest:
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GENERALFEES
SERVICES / POWER SUPPLIES
0 to 400 Ampere @ $25
401 to 800 Am ere $50
Above 800 Am ere $75
CIRCUITS I FEEDERS
0 to 200 Am ere $5 � t
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Uni�
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
L' hti Retrofit $.25 per Fixture
Center Pivot Irri ation Boom $40
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites (�a $5
Traffic Signal Standard
Supplemental Fee @ $
Transformers uo to 10
_ j Transformer / Power Suppry for Signs I Outline Lighting @$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 Inspection Trips @ $20
Investiqative Fee
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TOTALFEE I �r}�(j�}
(minimum total fee is $20)
I inspected the electrical installation described herein on the dates stated:
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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178L9160
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�,. vace: Rou h-in Ins ection Re uired? ❑Yes p g [�ReadyNow ❑WillCall
f £. n g p q 7[] No Ins ection Other Than Rou h-In:
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You must call the inspector when ready! . � Date Ready:
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I cer6fy that I am the LX1 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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',��sae o- cnaa�e� cry�FiIDLFY i'Ihl
�1�1 bTH ST 554�y��)7'
��, Township I, Section �, Range ! Fire No. �, County
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Owner/Occu ant Name wo (2) Phone Numbers Including Area Code
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ElecfricLal UtiliCty ./ Electrical Utility Address
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I Contractor / Company Name Contractor License Number � Master Electrician or Power Limited Technician
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MaiGng Address (Conhactor,�Company or Owner Performing Installation)
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! Authorized Si nature (Contractor or Owner Performing Installation) � I Please Provide Two (2) Phone Numbers Including Area Code
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INSTRUCTIDNS ON BACK OF VELLOW COPV Rf1ARfl nF FI Ff`TRI!'ITV !'l1PV �o nnnn. n,� o, ���.