P - 76565.u�cK ... . �
REQUEST FOR ELECTRICAL INSPECTION �
,,, �� p�- 9 0 4 6� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 x�tir�r.electricrh�.state.mn.us
Describe
0 l0 400
401 to 8
back of the white copy if necessa tne worK covereo oy �nis reques ;
EXC�L F_�lEF.GY �A�l�f� S S�fTTCH
(;FNFRAI FFFS OutdoorLightingStandard
SUPPLIES
ALARM, COMMUNICATION, REMU I t I:UN I Ku�, ��ti�
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
t
Supplemental Fee @ $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns I Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
TOTAL FEE I A?(�a(j(j
(minimum total fee is $20)
TNIS AREF GOR INSFECTOft USE ONLV
I hereby certify that I inspected the elecMcal installation described herein on the dates stated',
Center Pivot Irri ation 800m $40 °"`
Manufactured Home Park Lots $25
Recreationai Vehicle Park Sites $5 ���sPec��o� � o^TE
Se arate Bondin Ins ection $20 � � � '2 �~ � �
Special Inspectan @$30 per Hour exPiaeo nenr�oor�eo o^TE
Special Inspection @ $.31 per Mile
THIS IN$TALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS _____
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17819046 ` � �/
Date: Rough-in Inspection Required? ❑ Yes �] No '�, Inspection Other Than Rough-In: [�(Ready Now ❑ Will Call
II � f�' ����� i You must call the inspector when ready! .. Date Ready:
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I certify that I am the Lxl LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
_ _ __--_ _—_ _-�- y-,
�'�-Job Site Street Address �- �---- � -- � � � � � �_ j� � j`�{
i i�3?� {`i� I"��.��7� -CJ � � c c,z?'?_'1 rt�':r
Section
IOwner/Occupant Name
�.�L�)�i� ,•ri',���.��f� �
Fire
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Please Provide Two (2) Phone Numbers Including
\ / \ /
i Electncal Utility I Electrical Utility Address
�i�FL ChfE�iGv �
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�� Contractor / Company Name Contractor License Number Master Electrician or
�iUh�IT ELECTa�.'IC C['1F'.F'ORATIC7P�i ' ii� ��tjt3g;� LicenseNumber
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�Mailing Address (Contractor, Company or Owner Performing Installation)
sa0�) 1��;FIT��F.aAi_ �;C1AL�y �AIhiT F`AUL� �ihl `�`�f.i�
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Authorized S�gnature (Contractor or Owner Performing Installation) �I Please Provide Two (2) Phone Number
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wcroi �rnnue nu wecu nr vc� � nw cnav BOARD OF ELECTRICITY COPV
Technician I
; Induding Area
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