P - 76562'] REQUEST FOR ELECTRICAL INSPECTION
1� 1��- 9 21 O Minnesota Board of Electricity ,�,�` '
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
(651) 642-0800 TTY/MRS 1-800-627-3529 wx�x�.electricity.state.mn.vs
Describe -using the back of the white copy if necessa the Qrk oyered,by,(�i j sY
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GENERAL FEES Outdoor Lighting Standard @$1
SERVICES I POWER SUPPLIES Traffic Signal Standard @$5
0 to 400 Ampere $25 Supplemental Fee @$20
401 to 800 Am ere $50 Transformers u to 10 KVA $10
Above 800 Am ere $75 Transformers over 10 KVA $ 20
CIRCUITS ( FEEDERS Transformer I Power Su I for Si ns I Outline Li htin $5
0 to 200 Am re $5 ,c ONE 8 TWO FAMILY DWELLINGS, EACH UNI7
Above 200 Am ere $10 Indudes the Service and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALWG Circuits and Two inspection Tnps Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS TNAN 50 VOLTS Additional Ins ection Tri s $20
Each SysYem Device or Apparatus @$.50 Investigative Fee
ADDITIONS TO THE GENERAL FEES Reinspection Fee (a� $20
41LY DWELLINGS (PEI
2 Units @ $50 Per Unit
Additional Unit @ $25
FEES
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irriqation Boom (cJ �4C
I hereby
TOTALFEE '�(j�(j,�
total fee is $20)
I inspeded the elechical installation descnbed herein on the dates stated:
Se arate Bondin Ins Vction $20 V 4�--L.�, �-�' a�O
S iel I�specti0� $30 pe� HOU� exaiaeo nenNOO oA�E
S cial Inspection @$.3t per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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I Q1°� � Rough-in Inspection Required? ❑ Yes j�] No I Inspection Other Than Rough-In: [�Ready Now ❑Will Call
'� �' �"� ���6 � You must call the inspector when ready! '�� Date Ready:
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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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', Owner/Occupant Name� � , Please Provide Two (2) Phone Numbers Including
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' Eiectrical Utility —�Elecirical Utility Address
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ICHUhitT/ELEC7F:EC CD�'�'[j�i(�-(l��I�� ContrectorEe�nse���e�r} MasterElectricianorP
r License Number
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Mailing Address (Contrac[or, Company or Owner Performing Installation)
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��; puthorizad Sigoature (Con[ractor or Owner Performing Installation) ' Please Provide Two (2) Phone Numbers ��
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INSTRUCTIONS ON BACK OP YELLOW COPY BOARD OF ELECTRICITY COPY
Technician I
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