P - 77313REQUEST FOR ELECTRICAL INSPECTION
1��� O� O�� � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0B00 TTY/MRS 1-800�27-3529 www.electriciry.state.mn.us
EW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy 'rf necessary - the nrork covered by this request:
GENERAL FEES Outdoor L' htin Standard Li
SERVICES I POWER SUPPLIES . TraRc Signal Standard (a? 35
CIRCUITS OF LESS THAN 50 VOLTS
Su lemental Fee $20
Trarisfertners u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns I OuUine Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNtT
Includes the Service andlor Power Supply up to 500 Amperes, All �f �
Circuits and Two Inspection Trips Each Dwelling Unit @$80 ���rr
Additional Ins tion Tri $20
Investi ative Fee
Reinscection Fee � $20 . �i
3 to 12 Units @$50 Per Unit (minimum tOtal fce IS $20) �''` Z'}''(� �y�
E2Ch Addifi0�21 U�it @ S25 �ws u�, Faa �ear�ctae usE aar
I hereby certify Mat I inspecOed the electrical installa6on described herein on the da0es stated:
OTHER ADDITIONAL FEES � �1 C
Li h6n Retrofit $25 r Fixture � V I
Center Pivot Irri ation Boom $40 R°"�"" °"rE
Manufactured Home Park Lots 525 �C—�-----�./� �2^Id �
Recreational Vehicle Park Sites $5 Fn+ursr�craN / � � onrE
Se arate Bondin Ins Gon $20 <___..�'�'�'�' "� �' �•i �s
S ial Ins 'on E30 r Hour �x""EO`"�'a°'F° o�*�
Soacial Insoection (� 5.31 cer Mile
INI �l�� II IIl II�I II!!! III� II III IIIII �� II�I
17300765
IF NOT COMPLETED WITHIN 12 MONTHS _ �
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Request Date: Rough�n Inspedion Required? (".� Yes ❑ No Inspedion Other Than Rough-In: ❑Ready Now� Will Call
You must wll the inspector when ready! Date Ready:
I certify that I am Ihe �UCENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Address (Street, Box, or Route NoJ City Zip Code
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�+er Supplier
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ntractor / Company Name
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Please Provide Two (2) Phone Number(s) InGuding Area Code
or� ( ) ( )
Power Supplier Address
nnaumg naaress (wnaac�or, �c�pany or uwne
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Authorizsd Signature (Contrador, Company or i
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INSTRUCTONS ON K OF
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Contreda License Number Master Electrician or Power Limfted Technician
`�� �Q� � License Number
G.
ming Installatlon) ' / �/
�( : v'rr1C. /" °✓v �7 6 ��
rtning Instellation) Phone (s)
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BOARD OF ELECTRICT' COPY EB-00001A-14 8.1. 2002