P - 782711_ n n^_ c� c �c REQUEST FOR ELECry RICAL INSPECTION �1� ��
�� U'� U V j J Minnesota Board of Electrici
� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
` (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW ODEL O ADDITION ❑ REPAIR Describe -using lhe back of ihe white copy 'rf necess�y - the work covered by this request:
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GENERALFEES
SERVICES I POWER SUPPLIES
0 to 400 Amcere � S25
I CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units @$50 Per Unit
Each Addi6onal Unit @ $25
1 BOOrtI $4�
Park Lots
Park Sites
> tion
$30 cer Hour
Transformers u to 10 KVA $10
Transformers over 10 KVA S 20
Transformer / Power Su I for Si ns I Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Senice �dlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$BO
Additional Ins _ tion Tri $20
Inves6 ative Fee
Reins tion Fee $20
TOTALfEE
(minimum total fee is $20) L.�
iMIS MEA FIXt M15PECTpi USE OILY
I hereby ceAify Mat I inspected tlie ek�chit� insfaHa6on dexribed herein on the dates stated:
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ECTED IF NOT COMPLETED WITHIN 1
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1404696 5 �'�(%�
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Requ t Date: Rough-in Inspection Required? Yes ❑ No Inspection Other Than Rough-In: Ready Now O V1lII Call
��/� You must call the inspector when ready! Date Ready: j, J"I�(�
I certify Uiat I am the CENSED CONTRACTOR 0 COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Address (Street Box� or Route No.) CitY r- Zip Code
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Please Provide Two (2) Phone Number(s) InGuding Area Code
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Power Supplier Address
3 Contractor License Number Master Electrician or Power Limited Technician
License Number
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, canpany a owr,er Perfortni sta��euw,�
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, Company a Owner rming I Ilation) � Phone (s)
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'ELLOW COPY BOARD OF ELECTRICIT' COPV EB-00001A-74 e.t. 2002