P - 76456REQUEST FOR ELECTRICAL INSPECTION �
1� 7 9 3- 0 5 3� Minnesota Board of Electricity �r
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �,
- (651) 642-0800 TTY/MRS 1-800-627-3529 x�wH.elec7rrcity.state.mn.us
Describe -us+� the back of the white copy if necessary - the work covered by this request:
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GENERAL FEES J Outdoor
/ICES I POWER SUPPLIES Traffic S
0 to 400 Ampere (a� $25 Supplemental Fee @$20
Transformers up to 10 KVA @$10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns / Outline Li htin $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
Above 200 Am ere $10 �
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOITS
Each Svstem Device or Aooaratus Cc� $.50
3 ta 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Liqhtinq Retrofit a(� $25 oer Fixture
i Home Park Lots (
Vehicle Park Sites
Iherebycertifythatl
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Fee
Fee $20
TOTAL FEE 2� �
iimum total fee is $20)
the electrical installation described herein on the dates stated:
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Special Inspection @$30 per Hour `" '"`� F"""°°"`°�� °""
Special Inspection @ $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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I Date: � Rough-in Inspection Required? ❑ Yes �No I� Inspection Other Than Rough-In: �eady Now ❑Will Call
l��I ��� l,{J i You must call the inspector when ready! _�Date Ready: I
I certify that I am the,� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER antl hereby request inspection of the electrical work at:
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Job Site Street Address , y �� � ��' ^ f n n��
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Twvnship ��� Section � Range Fire No. 'I County �'� �L
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�I OwnedOccupant Name � Please Provide Two (2) Phone Numbers Including Area Code
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Electrical Utiiity Electncal Utility Address
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Confractor / Company Name � . Contractor License Number Master Electrician or Power Limited Technician
- ' ��, License Number
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I Mailing Address (Contractor, Company or Owner P orming Installation)
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. Authorizod Signature (Contractor or Owner Performing Installation) Please Provide Two (2) Phone Numbers Including Area Code
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