P - 76457REQUEST FOR ELECTRICAL INSPECTION '�'�
1� 7 9 3- 0 5 4 06 Minnesota Board of Electricity �� _� �` :�S'
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 wH�x�.electricity.slate.mn.us
Describe -using the bac�k�lthe white copy if necessary - the work covered by this request:
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GENERALFEES
SERVtCES / POWER SUPPLIES
0 to 400 Ampere (a� $25
� Above 200 Ampere @$10 �
A�ARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS (PER UNIT)
3 to 12 Units (cil $50 Per Unit
Center Pivot Irrigation Boom @
Manufactured Home Park Lots (
Recreational Vehicle Park Sites
Hour
Outdoor Liqhtinq Standard
Suppiemental 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
Additional Insoection Trios (� $20
TOTAL FEE � S , S�y
(minimum total fee is $20) v
THIS AqE4 FOR INSPECTOR IISE ONIY
I hereby certify that I inspected the electrical installation described herein on the dates stated:
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS _ �
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17930546
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I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER
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Job Site Street Address
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'� OwnedOccupant Name
Section
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and hereby request inspection of the electrical work at:
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Please Provide Two (2) Phone Numbers Including Area Code
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IElectrical Utility 1 I Electrical Utility Address -�--
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��. Contrector / Company Name Contractor License Number Master Electrician or Power Limited Technician
�� ���� � / !. �� ' '. ��.� j��)� � License Number
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Mailing Address (Contractor, Company or Owner Perform�lnstallation) � ��
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. Authorized Signature (Contractor or Owner Performing Installation) Please Provide Two (2) Phone Numbers Including Area C� �
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