P - 76560REQUEST FOR ELECTRICAL INSPECTION F
1����- 9 2 2 8 Minnesota Board of Electricity ,���_ '
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 ��ww.electricitv.s4ate.mn.us
Describe -using the back of the white copy if necessa the work covered by ihis re uest:
EXC�L FNERGI'� Spi1�Fi `.C,,' SW:CT11ii
GENERALFEES
SERVICES I POWER
0 to 400 Ampere
4Oi IO HOO AfI1DE
0 to 200 Am ere $5 12 -1C T
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Irrigation Boom @
i Home Park Lots I
Vehicle Park Sites
Traffic Signal Standard
Supplemental Fee @ $
Transformers uo to 10
� Transformer I Power Supply for Signs I Outline Lighting @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiaative Fee
TOTALFEE i ���Hy
m total fee is $201
that I inspected the electrical installation described herein on the dates stated:
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5 ciallnspection $.31 erMile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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L7819228
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�, °"/. //�[ ! Rough-in Inspection Required? ❑ Yes �] No I Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
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'� _ You must call the inspector when ready! _ �I Date Ready:
I certify that I am the Lxl LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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��obsaes� tAddress '�''YFhIDL�.Y ht�!
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4 Owner/Occupant Name � � �
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Fire No.
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Please Provide Two (2) Phone Numbers Including Area
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� tiecxncai unuty i Electrical Utility Address
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Contrector / Company Name � '�, Contractor License Number Y Master Electrician or Power Limited l
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�; MaiGng Address (Contractor, Company or Owner Performing Installation) -- �
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I Authorized Signature (Contractor or Owner Performing Installation) Please Provide Two (2) Phone Numbers Including Area
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INSiRUCTIONS ON BACK OF VELLOW COPY BOARD OF ELECTRICITV COPV ca_nnnn.e_�c