P - 771291 8 2 0-- 4� 6 '� REQUEST FOR ELECTRICAL INSPECTION
� .a ❑ 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 c�rf necessary - the work co�ered by this request:
0 to 400 Am ere $25
401 to 800 Am re$50
Above 800 Am re $75
CIRCUITS I FEEDERS
0 to 200 Am re $5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIO
Liqhtinq Retrofit na. $.25 per Fixture
Traffic Signal Standard
Suoolemental Fee C�D $
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling UnR @$80
Addftional Ins ection Tri s $20
Investigative Fee
Reinsoeciion Fee an. $20
TOTAL FEE � �a
total fee is $201 � (
I hereby certify th ed the electrical installation described herein on the date5staled:
ROUGMIN % ` TE� ^
S
FINAI INSPECTIIXJ DAiE
���-�'� /1.—.� -�� '
�ecial Ins $.31 r Mile
INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rough-in Inspection Required? �Yes ❑ No Inspection Other Than Rough �n: ❑ Ready Now ❑ Will Call
� 1,1 �r1 lf'� You must call the inspector when ready! Date Ready: ��( �, '�S
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Sde SVcet Address ��Y
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Township Section Range Fire No. Coun
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Electriral Utilit dre:
d_ / �
, Company or Owner Performing
do r er Perfortning Ins'
Please Provide Two (2) Phone Numbers I
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a
nse Number Master Elechician or P
License Number
Please Provide Two (2) Phone Numbers Including Area Code
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iN COPY �i _ EBA0001A-15 8.1. 2004