P - 77164REQUEST FOR ELECTRICAL INSPECTION �
1� 8 6 9- 2 2 4 4 Minnesota Board of Electricity �-
� �� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �.
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricfty.state.mn.us �a�
Describe -using the back of the white copy if necessary - the work covered by this request: �1�f O`��
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GENERAL FEES Outdoor Lightin Standard $1
SERVICES / POWER SUPPLIES Traffic Si nat Standard $5
0 to 400 Ampere $25 Cp�d Supplemental Fee $20
401 to 800 Am re $50 Transformers u to 10 KVA $10
Above 800 Amcere C� $75 Transformers over 10 KVA (� $ 20
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus $.50
ADDITIONS TO THE GENERAL FEES
Each Additional Unit @
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irrigation Boom (�a $4C
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Tri s @ $20
Investigative Fee
Reinsoection Fee Ccil $20
TOTALFEE I
total fee is $20) 3 1� `�
I hereby certify that I inspeded the electncal installatlon descnbed herein on Ne dates stated:
ROUGHIN ' � � ��e,�� � DATE
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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I lill II III � I� II III � III II II� I� Iil II III �� I�II
18692244
vace: Rough-in Inspection Required? ❑ Yes �IQo Inspection Other Than Rough-In: ❑ Ready Now � Will Call
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�\ ���—�� You must call the inspector when ready! Date Ready:
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I certify that I am the,�CICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Street Address City
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Electrical Utility Adc
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iy or wner Performing Installation)
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2) Phone Numbers InGui
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master eiec[naan or
License Number
Please Provide Two (2) Phone Numbers Including Area Code
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