P - 76016REQUEST FOR ELECTRICAL INSPECTION
1� 7 3 3� 2 5 2 � Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-500-627-3529 www.edectricity.state.mn.us
Describe -using the back of th� white py'rf necessary - the work coverr�i by this request:
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GENERAL FEES Outdoor Liahtlna Standard �$1
4u� to twu am re m�50 Transformers to 10 KVA $10
Atmve 800 Am re $75 Transfortners over 10 KVA $ 20
,URS / FEEDERS Transformer / Power Su I for Si ns / OuUine ' hti $5.
0 to 200 Am�re @$5 ONE & 1W0 FAMILY DWEWNGS, EACH UNR
Above 200 Am re $10 Includes the Service artd/or Power Supply up to 500 Am�res, All
tM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwellir�g Unit @$80
�UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL �
fIFAMILY DWEWNGS (PER UNI�
3 to 12 Unfts @$50 Per UnR
Each Additional Unit � $25
OTHER ADDffIONAL FEEE
Liuhtirm Retroffi [� $.25 �r Fixture
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I hereby certiiY tha
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total fee is $201 � �e
I Inspected the eledrical trista0atlai d�n'bed herein on the dates staUed:
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�LLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12
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"""'� Rough-In Inspectlon Required7 �es ❑ No Ins
� s�`� � pecdon Other Than Raugh-In: 0 Ready Now Ca0
You must cell the inspector when ready! Date Ready:
I certify that I am the ICENSED EONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Str�t Address CitY
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ICTIONS ON BACK OF YELLOW COPY
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Contrador License Num6er Master Electridan or Power Limited Technician
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�stallatlon) Please Provide Twro (2) Phorre Numbers Including Area Code
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