P - 77012REQUEST FOR ELECTRICAL INSPECTION �`�
1�� 2 l� ,� 4� 2 � 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 -using the back of the white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoor Lighting Standard $1
SERVICES I POWER SUPPLIES Traffic Siqnal Standard (� $5
401 to 800 Am ere $50
Above 800 Am ere $75
CIRCUITS / FEEDERS
0 to 200 Am ere $5
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITI01
Liqhtinq Retrofit a(�. $.25 per Fi�Aure
over
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiqative Fee
iviw�ree )
(minimum total fee is $20) o� �
THIS AREP FOR INSPECTOR USE ONLV
that I inspeded ihe electrical installation described herein on the dates stated:
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Special Ins ion $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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18204826
Date: Rough-in Inspection Required? ❑Yes � No Inspection Other Than Rough-In: ❑ Ready Now gWill Call
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You must call the inspector when ready! Date Ready:
I certity that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site SVeet Ad r I City /
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Township Section Range Fire No. Coun
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Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
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Electrical Utility �q Electrical Util' Ad ress
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Contrador / Company Name Conhador License Number Master Electrician or Power Limited Technician
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N1 [ OWN-� IL
Mailina Address (ConVa . Comoanv or Owner Performina Installation)
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(���) a7�-yva� (�3) s�Is�a� �
FR.fI(If1fItA-15 X 1 �MW