P - 77111coG REQUEST FOR ELECTRICAL INSPECTION �
1� 8 5 4� U' O V ��w�' Minnesota Board of Electricity �-;
- 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
_ (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe^r��t�� of the white� if necessary - the work covered by this request: �
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GENERAL FEES Outdoor Lightin Standard $1
SERVICES I POWER SUPPLIES Traffic Si nai Standard @$5
0 to 400 Ampere na. $25 Supplemental Fee @$20 . _ �, ��
;UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL
TIFAMILY DWELLINGS (PER UNIT)
3 to 12 UnRs @$50 Per Unit
FEES
Manufactured Home Park Lots $25
Recreational Vehicle Park Sftes $5
Se arate Bondin Ins ection a$20
Special Ins ection $30 per Hour
S ial Ins 'on $.31 per Mile
THIS INSTALLATION MAY BE
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18546861�
Transfortners over 10 KVA $ 20
Transformer / Power Supply for Signs I Outline Lighting @$5
ONE 8 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
(minimum total fee is
I hereby certity that I inspeded the elecfncal installatlon desaibed herein on the dates sfated: �
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) IF NOT COMPLETED WITHIN 12 MONTHS _____
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uate: � Rough-in Inspection Required? ❑ Yes ❑ No Inspection Other Than Rough-In: �'i�eady Now � Will Call
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� �s S You must call the inspector when ready! Date Ready:
I ce th I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elechical work at
Job Site SVeet Address City
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Township Section Range Fire No. County �
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Owner/Occupant Name Please Provide Two (2) Phone Numbers InGuding Area Code
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ElecVical Utility ElecVical Utility Address
Contractor / Company Name Contrador License Number Master Electrician or Power Limited Technician
_p /�/ _ / _� /' ✓ / / ��/ � License Number
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Mailing Address (Contractor, Compan or Owner Performing Installation)
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FR.(NNNItA-1E A 1 '