P - 78732REQUEST FOR ELECTRICAL INSPECTION �..
- Minnesota Board of Electricity
�� � 3 4 7- 3 0 3 �:v va mq �821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
a,�� � . (651) 642-0800 TTY/MRS 1-800-627-3529
www.electricity.state n
IdenYdy the work covered by this request: `, � s�
❑ NEW ❑ REMODEL ` ADDITION ❑ REPAIR l S ���� c�
0 to 400 Am ere �$25 �-- Su lemental Fee �$20
401 to 800 Am ere �$50 Transiortners u to 10 KVA �$10
Above 800 Am re �$75 Transfortners over 10 KVA �$20
CUITS / FEEDERS Transfortner / Power Su for Si ns / Outline Li Mi �$5
200 Am re �$5 _ ONE � TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere �$10 Includes the Service andlor Power Supply up to 500 Amperes, All
_._ __.....,...,..r,,.., nC�V1TC �n.ROn� cir.Nei wr, Circuits and Two Inspection Trips Each Dwelling Unit �$8(
ITS OF LESS THAN 50 VOLTS naamona� m c
Device or Apparatus �$.50 Investi tive Fee
12 Units � $50 Per Unit
Boom �
TOTAL FEE Sa
total fee is $20) l
I inapected the electrical installstion tkscribed herein on tAe tlfl �statea:
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THIS INSTALLATION MAY BE ORDEKtu u�VVnn�a. � �� �� ••� • ��-••.. __ - -- -- - - -
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FOR OP� USE ONLY
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Request Date: Rough-in Inspection Required? Yes ❑ No Inspecdon Ofher Than Rough-In: ❑ Ready Now Will Call
� 6 3 You must call the inspector when ready! Date Ready:
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY �Q OWNER and hereby request inspection of tlie electrical arork at:
Job Address (Street, Box, or Route No.) Cily �P �e
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Section Township Range Fire No. Counry
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p�u� Phone
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Power Supplier Address
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Electrical Contrador / Company Name C tredor License Number Master License Number
Mailing Address (Con c[or, Company or Owner Perfonning Installation)
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Authorized Signature (Contractor, a r Owner PeAorming Installatlon) P ne
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E d3 7/1!2 . BOARD OF ELECTRICITY COPV INSTBUCiIONS ON BACK OF YELLOW COPY