P - 77356REQUEST FOR ELECTRICAL If�.SP TION ���
�� 1��- 3 31 2� Minnesota Board of Electricity ��7�5 0�� ;r-: -
1821 University Avenue Suite S-128, Saint Paul, Minnesota �104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricitv.state.mn.us
Describe -using the back of the white copy if necessary - the work covered by this requesC
EkCEL EFlEKGY SAVER'S S4JITCN
GENERAL FEES Outdoor Liahtina Standard (�a $1
Above 800
UITS I FEE
0 to 200 Ar
Above 200
I CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
ADDITIONS TO THE GENERAL FEES
TIFAMILY DWELLINGS (PER UNIT)
3 to 12 Units (cD $50 Per Unit
Center Pivot Irrigation Boom @
Manufactured Home Park Lots (
Recreational Vehicle Park Sites
Supplemental Fee @ $20
Transformers up to 10 KVA @$10
Transformers over 10 KVA al� $ 20
indudes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Investigative Fee
Reinspection Fee
TOTAL FEE I � � L��
total fee is $201 � •
I hereby certify that I inspected the electncal installation descnbed herein on ihe dates stated:
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IIS FNSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS __ _ �
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III n I� I) I� II In I I II I� I IIN
17813312
i ��YL L� �(y �j �I Rough-in Inspection Required? ❑ Yes �] No I Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
� �You must call the inspector when ready! .�ate Ready:
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I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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�°��.����`Q�11��AGA ST 1�IE c�ryFFiIDLEY
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Please Provide Two (2) Phone Numbers Including Area Code
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I Electrical Utility I Electrical Utility Address
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�r�` G� riy Contrector se r� TMaster Electrician or Power Limited Techni
IC�`U(4°f'� tL�t..�C GOFiF•CIfiATIC�h! I ��t" ��7"Li'�i`,'7 i�ice�seNumber
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; Mailing Address (Contractor, Company or Owner-Performing Installation)
1�aOC� TEf�FiITCIFiIAL F:C1AD, S�1TNT F'FtUL, hthl 55114
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A rixed � � tu e(Contractor or Owner Performing Installation) I��aie�Pro�Q�a�Flh�ne � mbers Including Area Code
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