P - 77501REQUEST FOR ELECTRICAL WSPECTION ��
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1����- 9 4 2 O Minnesota Board of Electricity ,r""` ;:`�:
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �:
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriclty.state.mn.us
Descr�e �sing the back of the white copy if nee�e�s�r�-�the �I ��by� � r��esb �+ �ti! T� `( ��'. f I
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FEES
ITS I f
to 200
ALAKPA, GVMMUNICATION, REMOTE CONTROL, SIGNALING
f,IRCUtTS, GIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus (a� $.50
Unit @
FEES
� Retrofit @ $.25 per fixture
Pivot Irrigation Boom (�a $40
Outdoor Lighting Standard
� Trensformers up 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 andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Fee
Fee @ $20
TOTALFEE
iimum total fee is $20)
I hereby certify that I ir.spected the eledrical installation described herein on the dates stated:
S ate Bondi Ins ctbn $20 Z�- 'Z 6-� �
S ial InSpeCtion @$30 p2f HOU� emiaeo aanrvooneo oArE
Special Irm ction $.31 per Mile
THI$ iN3TALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
I�N II I� B�� II I� II I� I I IH II II I II IN I) � I�II
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' 1e". �I Rou h-in Ins ection Re uired?
:,: �I , g p q ❑ Yes J� No i Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
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L.. j You must call {he inspector when ready! '�. Date Ready:
I certify that I am the Ll LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
� Jop Site Sheet Address
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. OwnerlOccupant Name -�� � �
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i Electrical Utilitv Address - -
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Phone Numbers I
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�wn�acwi i wmpany rvame , Contractor License Number ' Master Electrician or Power Limited
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Mailing Address (Contractor. Company or Owner Performing Installation) - - -�
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Author¢ed Si nature (Contractor or Owner Performing Installation) - � Please Provide Two (2) Phone Numbers Including Are
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INSMUC7lONS ON BACK OF YELLOW COPY 80ARD OF R FCTRICITV C(1PV �o nn��,., ,