P - 76458REQUEST FOR ELECTRICAL INSPECTION
1� 1 V�- 910 7 Minnesota Board of Electricity ��e�_ '
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 wx�H.elecjricity.state.mn.us
qescnbe -using the back of the white copy if neG�s a: the rk.�q.ve[gs�by,t�is je�pu�st; ,_ r, ,��,.,, ,
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`GENERAL FEES Outdoor Lighting Standard @ $1
SERVICES / POWER SUPPLIES Traffic Signal Standard @$5
0 to 400 Am re $25 Supplemental Fee @$20
401 ro 800 Am ere $50 Transformers u to 10 KVA $10
Above 800 Am re $75 Transformers over 10 KVA $ 20
CI CUITS i FEEDERS Transformer I Power Su I for Si ns I Outline Li htin $5
0 to 200 Am re $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
A6ove 200 Am re $�0 Includes the Service andlor Power Supply up to 500 Amperes, All
AI_qRM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ection Tn s $20
Each System Device or Apparatus @$.50 Investigative Fee
ADDITIONS TO THE GENERAL FEES Reinspection Fee @$20
MULTIFAMiLYDWELLINGS PERUNIT TOTALFEE :?isi�!;•"i
3 to �2 Unks �? S50 Per Unit (minimum total fee is $20)
FEES
Pivot Irrgation Boom @
�ctured Home Park Lots i
tional Vehicle Park Sites
I hereby ceRify that I inspected the electrical installation described herein on the dates stated:
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TM!$ !#ISTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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' �`0`e. � Rough-in Inspection Required? LIYes $..1NO 'I Inspection OtherThan Rough-In: L}Ready Now LJWiII Call
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I' � i You must call the inspector when ready! I Date Ready:
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I certify that I am the L7 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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. Job Site Street Address Cit ' `�% �- ��� `'
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�� ToNlnship � Section I Range j Fire No. � County
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i, Owner/Occypan4 Name � y � Please Provide Two (2) Phone Numbers Including Area Code
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Eleckical Utili� �, Electrical Utility Address
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I Contracfor / Company Name � Contractor License Number�Master Electrician or Power Limited Technic
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Wailing Address (Contractor, Company or Owner Performing Installation)
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i Ail�i�rixed S' ni�p ature (Contrector or Owner Performing Installation) �� Please Provide Two (2) Phone Numbers Including Area Code
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