P - 765631 7 81 915 2 REQUEST FOR ELECTRICAL INSPECTION ,
� � ❑ Minnesota Board of Electricity ,
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �,
(651) 642-0800 TTY/MRS 1-800-627-3529 wwH�.electricity.state.mn.us
Describe -using the back of the white copy if ne �- the r e�g .by,(�i ��% t, T t
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SUPPLIES
0 l0 400
401 to 8i
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY
3to12Ur
Lighting Retrofit
Center Pivot Irri�
$50 Per Unit
Unit @ $25
OTHER ADDITIONAL FEES
@ $.25 per Fixture
�ation Boom (� $40
Outdoor
Traffic Signal Standard @ $5
Supplemental fee @ $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns / 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
TOTALFEE I �+��t��
(minimum total fee is $20)
I inspected the elecUical installation described herein on the dates stated:
Se arate Bondin Ins ection $20 �-�" �' �
S Cial InSpBCtiOn $30 p0� HoU� exaieeo nenr�ooNec onre
S cial Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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Range
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� Owner/Occu nt Name — �— - - --
Pa , Please Provide Two (2) Phone Numbers Including Area Code
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; Eleetrical Utility I; Electrical Utility Address �
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� CHU �1" / E�..�rTk:C � GCJ�;I-�(7fiA'j" Contractor License Numbe Mr aster Electrician or Power Limited Techni
r � � � ��� ��I �^� �V�rr,�� IiLicenseNumber
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I Ma�ling Address (Contractor, Company or Owner Performing Installation)
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IAuthonzed Si nature Contractor or Owner Performin Installation Please Provide Two (2)�Phone Numbers Including Area Code
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FNSTRUCTIONS ON BACK OF YELLOW COPY BOARD OF ELECTRIGTY COPY EB-00001A-15 B.1 2004