P - 765691 REQUEST FOR ELECTRICAL INSPECTION
1�� V 1- 911 1 Minnesota Board of Electricity �,t` '
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �. ,
(651) 642-0800 TTY/MRS 1-800-627-3529 wwN�.elecjricity..rtate.mn.us
Describe -using the back of the white copy if necessa the work covered by this re uest:
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GENERALFEES
SERVICES I POWER
0 to 200 Am ere $5 rQ -� t
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or ApparaWS @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit (c� $25
lighting Retrofit @ $.25 per Fixture
Center Pivot Irrigation Boom @ $4C
Manufactured Home Park Lots @ $
Recreational Vehicle Paric Sites (� ;
Outdoor Lighting Standard
Traffic Sianal Standard (c� 9
Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
Transformer I Power Supply for Signs I 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
Fee
Fee
iviA�ret L;J,��
total fee is $20)
iha� I inspected the electncal installation descnbed herein on the dates sta�ed:
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SpECial InSp2Cti0n $30 p2� HoU� exaieeo naneeewso-- oATE
Special Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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� va�e. Rough-in Inspection Required? ❑ Yes
?[] No I, Inspection Other Than Rough-In: �Ready Now ❑Will Call
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�__ �YOU must call the inspector when ready! �� Date Ready:
I certify that I am the L�] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electriral work at:
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Job Site Street Address c;�y �� j� ��=f M�
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�� Township �Section rRange ,� Fire No. I County
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; QwnedOic,cupant Namen � �- �Please Provide Two (2) Phone Numbers Including Area Code
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�oncracmr i �ompany rvame I Contractor License Number � Master Electrician or Power Limited Techni
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Mailing Address (Contractor, Company or Owner Performing Installation) � �� - -
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�� Authorized Si nature (Contractor or Owner PeRorming Installation) I Please Prowde Two (2) Phone Numbers Including Area Code
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