P - 77232REQUEST FOR ELECTRICAL INSPECTION
1—�`"—�� O � 1821 Unv ersi� Ae nue 8u'd�e S- 28, Saim Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
EW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using the bxk of the white copy if necessary - the vrork covered by this request:
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GENI
I POWER SUPPLIES
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or ratus $.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @ 350 Pe
Each Additional Unit @
Center Pivot Irtigalion Boom
Manufactured Home Park Lc
Outdoor Li htin Standard S1
Traific Si nal Standard $5
Su lemental Fee @ $20
Transformers u to 10 KVA $10
Transfortners over 10 KVA $ 20
Transfortner I Power Su fa Si ns I Outline Li htin $5
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 @$60
� total fee is $20) � ��•� �
rws naEn FoR usaECroa usE a._r
I hereby certify Nffi I inspected the elecfical installation described herein on the dates stated:
S ial Ins tion 5.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MOI
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Request Date: Rough�n Inspection Required? ❑ Yes �!b InspecGon Other Than Rough-In:�Ready Now ❑ Nhll Call
1.' —'� �— Q S 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 Address (Street, Box, or Route No.) City Zip Code
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11C VELLOW COPY
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OF ELECTRICITV COPV
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Please Provide Two (2) Phane Pkimber(s;
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ense Number Masler Electriclan or
�? � � License Number
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EB-00001A-/4 8.1.2002