P - 76465REQUEST FOR ELECTRICAL INSPECTION ��
1� f V�- 912 � Minnesota Board of Electricity �� ._
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 N�ww.electricity.state.mn.us
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I POWER SUPPLIES
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FEES
Above 200 Am ere $10 �
ALARM, COMMUNICATI�N, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svsfem Device or Aaoaratus na $.50
to 12 Units Q$50 Per Unit
ach Additional Unit @ $25
OTHER ADDITIONAL
cthtinq Retrofit (�a $.25 cer Fixture
Hour
Outdoor Liqhtinq Standard
Suppiemental Fee @ $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns I Outline Li htin $5
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
TOTAL FEE ::'�.1a .:•�_
(minimum total fee is $20)
iH15 AftEA FOR INSPECTOR USE ONLV
I hereby certify that I inspected the electrical installation described herein on the dates stated:
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Tt118 MFSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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�a�� __ . __ � You9musticalPthe_inspeotor when O dys :[] No 'i
Inspection Other Than Rough-In: Q:Ready Now ❑ Will Call
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_ _ Date Ready: _
I certify that I am the `L'��1 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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��FOwnsh�p �� Section Kange ��, Fve No. I Gounty
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Owner/Occupant Name ��Please Provide Two (2) Phone Numbers Including Area Code
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�. �Iectrical UtiNty '� Electrical Utiliry Address
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i Contractor / Company Name �_ i Contractor License Number �aster Electrician or Power Limited Technician
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MaiWig Address (Contractor, Company or Owner Performing Installation)
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, quthorusd S' nature (Contractor or Owner Performing Installalion) �,, Please Provide Two (2) Phone Numbers Including Area Code
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INSTRUCTIQNS ON BACK OF YELLOW COPY BOAR� OF ELEC7RICITV COPY �� EB-00001A-15 8.1. 2004