P - 77666REQUEST FOR ELECTRICAL INSPECTION
1��� L� � 61 �� Minnesota Board of Electriaty
1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
(651) 642-0800 1TY/MRS 1-800-627-3529 www.electriciry.state.mn.ur
❑ NEW REMO L❑ ADDITION REPAIR Describe -using the back of th�ite copy ff necessary - the xrork covered by this request:
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GENERAL FEES Outdoor Li htin Standard a1
SERVICES I OWER SUPPLIES TraRc Si nal Standard $5
� 0 to 400 mpere @ 5 Suoolemental Fee (a 520
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
2 Units @ $50 Per Unit
Additional Unit @ $25
OTHER ADDITIO
ng Retrofit @ $.25 per Fixture
:r Pivot Irrigation Boom � $4(
factured Home Park Lots � �
:ational Vehicle Park Sites (al.
raie Bonding Inspection @ S2
al Inspection �D S30 cer Hour
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17126111
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
TOTALFEE �^
(minimum total fee is $20) � �� J �
THIS AREA FOR INSPECiqi USE IXJIY
I hereby cer6fy lhat I inspected the ek�cbical insGllation described herein on the dates sfated:
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�MPLETED WITHIN 12 MONTHS _ I
Kequesc uace: Rough-in Inspection Required? ❑ Yes � No Inspedion Other Than Rough-In: ❑Ready Now Will Call
9' C�' �S You must call the inspecta when ready! Date Ready: g— v' �
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of tt� elecfical work at:
Job Site Address (Street, BoX a Route No.) City Zip Code
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Power Suppli
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Cantractor / Company Name
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Mailing Address ( or pan or Own�
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Authorized Signa ( ompan or
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Please Provide Two (2) Phone Number(s) InGuding ,
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Address
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Contrada License Number aster ec6ridan or Power Limite
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BOMD OF ELECTRICITV COPY
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Phone (s)
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EB-0OOO1M/4 8.1.2002