P - 77125REQUEST FOR ELECTRICAL INSPECTION �'��
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1� V 2�� 3 7 6 � 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 ?�_�
Describe -using the back of the white copy if necessary - the work covered by thi request: ,
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GENERAL FEES Outdoor Lighting Standard @$1
/ POWER SUPPLIES
Above 800 Am ere � b75
CIRCUITS / FEEDERS
0 to 200 Am ere $5
Above 200 Am re $10
ALARM, COMMUNiCATION, REMOTE CONTROL, SIGI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Ap aratus $.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Pe
Each Additional Unit @
Li htin Retrofrt a$.25 er Fixture
Center Pivot Irtigation Boom $40
Manufactured Home Park LoGs $25
Recreational Vehicle Park Sites $5
Se arate Bondin Ins ection $20
Special Inspection $30 per Hour
Special Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED D
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18223768
Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, Ail
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiaative Fee
TOTALFEE
total fee is $201
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I hereby certify that I inspeded Ne electrical installation described herein on the dates stated:
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FINALINSPECTIO . � C� oATE
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NOT COMPLETED WITHIN 72
Date: Rough-in Inspection Required? �'es ❑ No Inspection Other Than Rough-In�eady Now ❑Will Call
�(f���`Q 7 You must call the inspector when ready! Date Ready:
I certify that I am the�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work aY.
Job Sfte SUeet Address ��Y
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Township Section Range Fire No. County
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Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
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Contractor / Company Name G
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Mai i Addre (Contra�' C pany or Owner P orming/ nstallation)
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Authorized SignaWre (Cqntrador or Owper Perfartning Installation)
�nVactor License Number Master ElecUician or Power Limitetl Techn6
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Please Provide Two (2) Phone Numbers Including Area Code
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