P - 76571REQUEST FOR ELECTRfCAL INSPECTION
1� 7 8 1� 9 0 8 � Minnesota Board of Electricity ,
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �: 1
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.stale.mn.us
Describe -using the back of the white copy if ne�s the rk o eLed,by i st;
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GENERAL FEES Outdoor Lighting Standard @$1
SERVICES I POWER SUPPLIES Traffic Signai Standard @$5
0 to 400 Ampere @$25 Supplemental Fee @$20
401 to 800 Am ere $50 Transformers u to 10 KVA $10
Above 800 Am re $75 Transformers over 10 KVA $ 20
CIRCUITS I FEEDERS . Transfnrmar / Pnwar Siinnlv fnr Sinnc /(luflinc I inhfinn �l 4F
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 Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
L'ghting Retrofit @ $.25 per Fixture
Center Pivot Irriqation Boom (� $40
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ection Tri s $20
Investigative Fee
Reinspection Fee @ $20
TOTALFEE L�e�,��
(minimum total fee is $20)
that I inspected the elecMcal installation described herein on the dates stated: �
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5 cial Inspection @$30 per Hour exaiaeo nenNOOneo
Special Inspection @ $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MO
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� uaie: �� Rough-in Inspection Required? ❑Yes ;[] No ��, Inspection Other Than Rough-In: [�Ready Now ❑Will Call
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'�_ You must call the inspector when ready! �I Date Ready:
I certify that I am the �'] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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Job Site Street Address City � � � � � � �; � �
14�. h;'L-" 7EzTH W�'�Y
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., Township � � I Section � � Range '� Fire No. i County
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I� Owner/Occupant Name � - Please Provide Two (2) Phone Numbers Induding Area Code
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�,' Electrical Utility ', Eledrical Utility Address
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Contractor / Company Name I '�. Contractor License Number �� Master Electrician or Power Limited Technici
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iMailing Address (Contractor, Company or Owner Performing Installahon) �� �
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: AunthorizQd Signature (Contractor or Owner Performing Installation) Please Provide Two (2) Phone Numbers Including Area Code
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