P - 80069REQUEST FOR ELECTRICAL INSPECTION
1� 3 2 2- 0 51 e� e Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
p m (651) 642-0800 TTY/MRS 1-800-627-352
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www.electricity.state.mn.us �� '�-'
Itlentity the work covered by this request: /�
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EW ❑ REMODEL ❑ ADDITION ❑ REPAIR
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am re d$25 Su lemental Fee �$20
401 to 800 Am re �$50 Transfortners u to 10 KVA �$10
Above 800 Am re �$75 Transfortners over 10 KVA �$20
CIRCUITS / FEEDERS Transfortner / Power Su for Si ns / Outline Li hti �$5
0 to 200 Am ere (� ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re �$10 Includes the Service andlor Power Suppty up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellin Und �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri �$20
Each S tem Device or A aratus �$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reinspection Fee �$20
3 to 12 Units (� $50 Per Unit (mmimum totai tee is �zo) c�=-
Each Additional Unit �$25 fOP INSPECTOP USE ON�Y
OTHER ADDITIONAL FEES ��G/� /r.-/�o"''
Li htin Retrofit �$25 r Fature
Center Pivot Irri ation Boom �$40 .
ManUf2Ctllfe(1 HOflle Pafk LoIS �$25 I he certily tt�at I inspecled the electrical installation described herein an tl�e dates stated:
Recreational Vehide Park Sites �$5 "01GH1N DA7E
S rate Bondin In ion �$20
S'al Ins ion �$30 r Hour `�10N DA7E
S ial Ins ection �$.31 r Mile �- -�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFFlCE USE ONLY
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Request Date: RougMin Inspection Required7 ❑ Yes o Inspection Other Than Rough-In: Ready Now � Will Call
'-p"� (,� � You must call the inspector when readyl Date Ready:
I certiiy that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspectlon of the electrical work at:
Job Address (SVeet, Box, or Rou[e No.) City Zip Code
I G5'S 73,eo v� �v�
Sedion Township Range Fke No. County
Phone
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Power Supplier
E ctncal Gontractor / Gompan Name Contractor License Number Master �icense Number
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Mailing Address (ConVactor, Company or Owner Performi�g Installation) p
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Auth ' g re(Contractor, Company Owner erf ing Installatlon) Phone
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