P - 76159REQUEST FOR ELECTRICAL INSPECTION
1��� o- 5 6 3� Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.elecJricity.state.mn.us
�esai e-using t e back of the whit� PY � - the work comered this req : � L; ,,__, � „[�t - rv
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GENERAL FEES Outdoor Liahtina Standard no �1
I SERVICES /
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCURS OF LESS THAN 50 VOLTS
Each S em Devic;e or Apparatus @$.50
ADDffIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Ead� Additional Unit f�a $25
SitaS
TraRc Sinnal Standard
ONE 8 NVO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Cirtwits and Two Iruspection Trips Each Dwelling Unit @$80
Addfional Ins ' n Tri s@$20
Investigative Fee
Reins 'on Pee $20
TOTALFEE
(minimum total fee is $20) � � ' �
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I hereby cert(ty that I inspeded the electrical 6�sfellatlon descr(bed herein on fhe detes siated:
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� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTH�
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�j g pectlon Requlred? ❑Yes No Inspectlon OtherThan Rough-In: ❑ Ready Now Cap
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I certify that I am the � LICENSED CANTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspe�ion of the electrical work at
Job Site Street Address �gy
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Tawnship Sedon Range Fire No. County
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O/w➢ner/ Name Please Provide Two (2) Phone Numbers Including Area Code
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Electrical Utllity Eledrical Utility Address
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Contractor / Compeny Name � Conhactor Llcense Number Master Electrician or P r Limited Technician
�� /� � �C Ce �I � � � /� Q � f � � Licerise Number
Maling Address (Contractor, Company or Owner PerForming Ins1a11aUon)
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Auth SI re ( r or r PerFortning Installatl Please Provide Two (Z) Phorre Numbers Includhig Area Code
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