P - 76634REQUEST FOR ELECTRICAL INSPECTION �`�
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2� o��� 6� 3� Minnesota Board of Electricity � ,�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �,.
(651)642-0800TTY/MRS1-S00-627-3529 www.electriciry.state.mn.us ��
Describe -using the back of sqe white copy if necessary - the work covered by this request:
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' GENERAL FEES Outdoor Li htin Standard $1
S RVICES / POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Amoere (� $25 Supplemental Fee @$20
Above 200 Ampere $10
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus $.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS (PER UNITI
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighting Retrofit @ $.25 per Fi�ure
Center Pivot Irriqation Boom Ccil $40
Special Inspection $30 per Hour
Special Inspection $.31 per Mile
THIS INSTALLATION MAY I
I�III II�II �III) I I�I IIIII IIIII (IIII II II II� (IIII
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Transformers u to 10 KVA $10
Transformers over 10 KVA a$ 20
Transformer I Power Su I for Si ns / Outline Li htin $5
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
TOTALFEE �
total fee is $20) 3 �� `�
I hereby certi(y that I inspected the eledrical installation described herein on the dates stated:
RWGHIN pATE
FINPIINSPECTION pq�
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E%PIRE�IABANDONED DATE
;CTED IF NOT COMPLETED WITHIN 12 MONTHS
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Rough-in Inspection Required? ❑Yes��No Inspection Other Than Rough-In: eady Now ❑Will Call
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��/Li�� You must call the inspector when ready! Date Ready:
I ceRi(y that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site SVeet Address C�y
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mpanyName
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:(Contractor, Company or Owner Performing In
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I�ature acto-- rorOwne� orminglnstall
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)N BACK OF YELLOW COPY e�
Please Provide Two (2) Phone Numbers I
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Contractor License Number I Master Electrician or Power Limited Technician l
� A � � , _ , , License Number /� /1 ., _ r . . � �
Please Provide Two (2) Phone Numbers
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