P - 77764REQUEST FOR ELECTRIC L INSP TIOI�, °''��'F�„
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s s Minnesota Board of Electricit b Q� U �
1821 University Avenue Suite S-128, Sa nt Paul, Minnesota 55104 �,.'
(651) 642-0800 TTYIMRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy if necessary - the work covered by this re Quest:
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GENERAL FEES Outdoor Lighting Standard @$1
SERVICES I POWER SUPPLIES _ . Traffic Sianal Standard na $5 /� _
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Ap aratus $.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units CaD $50 Per Unit
S ecial Inspection @$.31 er Mile
THIS INSTALLATION MAY BE
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two inspection Trips Each Dweiling Unit @$80
Additional Ins ection Tri s $20
Investi ative Fee
Reins ction Fee $20
TOTAL FEE `v
(minimum totai fee is $20) Z�� �
THISAREA FOR INSPECTOR USE ONLV
I hereby certifv that I inspected the electrical installation described herein on the dates siffied:
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18299354
Date:(�,� � Rough-in Inspection Required? ❑ Yes �(Jo Inspection Other Than Rough-In: ❑ Ready Now�Vill Call
`( � J I V'� You must call the inspector when ready! Date Ready:
I certify that i 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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Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
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Electrical Utility Electrical lity Address
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Contractor / Company Name Contrador License Number Master Electrician or Power LimRed Technician
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Mailing Address (Contrador, Company or Ow r Perfo ing Installation)
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Author' gna re Contract or O Performing Installation) ease Provide wo (2) Phone Numbers Including Area Code
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