P - 76511REQUEST FOR ELECTRICAL INSPECTION �'�
1� 9 6��r, �,�,.� � Minnesota Board of Electricity �. �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
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(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us ��
Describe -using the back of the white copy if cessary - the wo covered by this request:
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GENERA ES Outdoor Li htin Standard $1
SERVICES / POWER SUPPLIES Traffc Si nal Standard $5
1 0 to 400 Amoere na $25 O� 0 Supplemental Fee @$20
�M, COMMUNICATION, REMOTE CONTROL, SIGNALING
:UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
TIFAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES _
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irrigation Boom @ $40
ManuFactured Home Park Lots l� $25
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / Outline Li htin $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
Additional Inspection Trips @ $20
Investigative Fee
Reinspection Fee na. $20
TOTALFEE
total fee is $20) �a�'
that I inspected the electrical installation described herein on the dates stated: �
Se arate Bondin Ins ection $20 -��``---�`��
Special Inspection @$30 per Hour exPiaeoinenNOOeeo
Special Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 M
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Date: Rou h-in Ins ection Re uired? ❑ Yes o Ins
,/ � �� g p q pection Other Than Rough-In: eady Now ❑Will Call
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You must call the inspector when ready! Date Ready:
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I ceRify that I am the f�'LICENSED CONTRACTOR �[ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Street Address ��y
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Township Section Range Fire No. � County
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OwnerlOccupant Name Please Provide Two (2) Phone Numbers Inciuding Area Code
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/CompanyName
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iress (Contractor, Company or Owner Perfortning Installation)
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i Signa�ture (Contractor or Owner Perfwmina Installationl
rador License Number Master Elechician or Power Limited T
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�. Provide Two (2) Phone Numbers I
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