P - 75736REQUEST FOR ELECTRICAL INSPECTION �
I 1��� lJ = 5 0 9 0 Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
Describe -using the b ck of the white copy'rf necessary - the arork covered by this u�t:
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GENERAL FEES Outdoor Liphtinp Standard Ca� $1 �
401 to 800
Above 8I10
�UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each_System Device or Apparatus � $.50
ADDRIONS TO THE GEMERAL I
fIFAMILY DWELLINGS (PER UNIT)
3 to 12 Unfts Cdl $50 Per Unit
Home Park
INSTALLATION MAY BE ORDERED E
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18805093
Tra�c
Transfomrers over 10 KVA � ZO
Transformer / Power Su I for Sigr�s / Oudine Lightlng @$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNR
Includes the Service andlor Power Supply up to 500 Amperps, All
Circutts and Two InspecUon Trips Each Dwelling Unit @$BO
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TOTAL
total fee is ;
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nre e�ecmcal m�el�anon de�bed nereb, on nre aat� smtea: I
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COMPLETED WITHIN 12 MOI
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D�: Rou h-in Ins ,-.1,L
� g pectlon Requir�? ❑Yes No Inspectlon OtherThan Rough-In: �.�pceady Naw ❑WUI Cell
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I certify that I am the 1� LICENSED CONTRACTOR ❑ COMPANY 0 OVNNER and hereby r�uest inspection of the electrical work at
Job Sife Street Address �(ty t��
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Township Secdon Range Fire No. Cou� �
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Owner/Occupant Name Please Provide Two (2) Phorre Numbers Includ'mg Area Code
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Electricel ULTity Electrical UhTity Addrega
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Contractor / Company Name ' Coritraactor License Number Master ectridan o ower Limited TechNclan
�/v /� �/e G/ //�� � l � a d o� License Number
Mailing Address (Contrador, Company or Owner Perfortning Installation)
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Authorized Sig ( ontrador o Oamer PerfortnNg Insfalladon) Please Provide Two (2) Ph/ona Numtrers Includ'mg Area Code
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INSTRUCTION N BACK OF YELLOW COPY BOARD OF ELECTRICfIY COPV eA.mttxftn-�5 a � �nna