P - 76408ry REQUEST FOR ELECTRICAL INSPECTION �
G f o 2�� 3 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
De�cribe -using the back of the white copy if necessary - the work covered by this request:
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GE ERAL FEES Outdoor Li hting Standard $1
SERVICES I POWER SUPPLIES Traffic Si nal Standard $5
0 to 400 Ampere $25 — Supplemental Fee @$20
401 to 800 Am re $50 Transformers u to 10 KVA $10
Above 800 Am re $75 Transformers over 10 KVA $ 20
CIRCUITS I FEEDERS Transformer / Power Su I for Si ns / Outline Li htin $5
0 to 200 Am re $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am re $10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ion Tri s $20
Each S tem Device or Ap aratus $.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ion Fee $20
MULTIFAMILY DWELLINGS PER UNIT TOTAL FEE �
3to 12 Units @$50 Per Unit (minimum total fee is $20) J,�
EeCh Addltl0f191 UnR @$25 THIS AREAFOR INSPECTOR USE ONLY
OTHER ADDITIONAL FEES I
� Retrofit @$.25 per Fixture I hereby certity that I inspeded the elecVical installation described herein on the dates stated
Proot Irriqation Boom l� $40 Rouc� �N oA,E —�
SeV rateBondin I s��ionc,$20J __✓ 2n 27.,�"'7
Speciallns I fl $30 �iiOUf Ex�aEOrneavooNE oA�
S' specti n $.31 r Mile
T _ T L__ TION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12_MONTHS ____ __
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Date: Rou h-in Ins
�� � g pection Required? ❑Yes No Inspection Other Than Rough-In: ❑ Ready Now Will Call
You must call the inspector when ready! Date Ready:
I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work ai
Job Site Street Address �� C�
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Township Se n Range Fire No. ComN
riease rroviae � wo (2) Phone Numbers InGuding Area Code
f1�G1Srt I-� �b (76� a,-
trical Utility Address
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Cantredor License Number Master Elect cian or Power Limited Technician
_ � A/N� n�. .�l License Number
a- �� � � � �G�' ��o � %rin �J�
u Con actor or Owner rtning Installation) Please Provide Two 2) Phone Numbers Inclu ing A Code
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