P - 76591pq REQUEST FOR ELECTRICAL INSPECTION ���'F�
��� O�i �-151 � Minnesota Board of Electricity k� �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �.r -�,.�
� �� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us �;�
Describe -using the back of the white co y if necessary - the work covered by this request:
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GENERAL FEES Outdoor Li hting Standard @$1
SERVICES / POWER SUPPLIES Traffic Siqnal Standard C� $5
0 to 200 Am ere $5 '— �
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Liphtinq Retrofit (�a $.25 oer Fixture
ued Home Park Lots a$25
nal Vehicle Park Sites $5
Bondin Ins ection $20
spection @ $30 per Hour
s ion @ $.3t r Mile
ALLATION MAY BE ORDERED I
!II�I IIIII IIIII IIIII IIIII IIIII IIIII IIIII �� I�
18421511�
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 Ins tion Tri s $20
Investigative Fee
Reinspection Fee $20
TOTAL FEE
(minimum total fee is $20) � �
nnsa�n Foa iNSaecroa usE ornv
I hereby certify that I inspected the electncal installation descnbed herein on the dates stated:
�NNECTED IF NOT COMPLETED WITHIN 12
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Date: Rough-in Inspection Required? ❑ Yes No Inspection Other Than Rough-In: � Ready Now ill Call
��/Q �`� J You must call the inspector when ready! Date Ready:
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Street Address �gy
73� .7 �' S{" �� r� c,� l�.e
Township Section Range Fire No. County
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OwnedOccupant Name Please Provide Two (2) Phone Numbers Including Area Code
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ElectricalUtilit � . tilityAddress
13562 GsMral ve 1�
763-757-6202
:omoanv or Owner Performii
� Authoraed SignaturejContrador or
License Nuryryry���eee r{ Master Electncian or Power Limfted
-'�1 � ")(� /_ License Number
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Please Provide Two (2) Phone Numbers Including Are
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