P - 77176REQUEST FOR ELECTRICAL INSPECTION ,� �`��
1� Q 2�°� Q O � Minnesota Board of Electricity �= ` �
�� v ❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 ��
r (651)642-0800TTY/MRS1-800-627-3529 www.electriciry.state.mn.us �""�
Describe -using the back of the white copy if necessary - the work covered by this request:
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GENERAL FEE Outdoor LiQhtinq Standard (a� $1
0 to 400 Ampere $25
401 to 800 Am re $50
Above 800 Am ere $75
CIRCUITS / FEEDERS
0 to 200 Am re $5
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Li hting Retrofit @$.25 per Fixture
Center Pivot Irrigation Boom $40
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites $5
Se arate Bondin Ins ion $20
Special Inspection $30 per Hour
S ecial Ins ection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED
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Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
Transformer I Power Supply for Signs I Outline Lightinq @$5
ONE 8 TWO FAMILY DWEILINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
TOTAL FEE L� � K � �
(minimum total fee is $20) 7'
TNIS NREA FOR INSPECTOR USE ONLY
I hereby cerliTy that I inspected the eledrical installation described herein on the dates stated:
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FIN4L INSPECTION .. � `/��
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E%PIREDIABPNDONEO DATE
CTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rough-in Inspection Required? es ❑ No Inspection Other Than Rough-In: ❑ Ready Now �Vill Call
f�/ ��� You must cail the inspector when ready! Date Ready:
I certify that 1 am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Street Address City
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Township Section Range Fire No. County
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Own Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
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Electrical Utility Electrical Utility Address
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Contttrrr��� dor / Company Name Contrador License Number Master Electrician or Power Limited Technician
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Mailing Address (Contractor, Company or Owner Performing Installation)
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Authorasd Signature (Con ctor or er Perfortning InstallaGon) Please Provide Two (2) Phone Numbers InGuding Area Code
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