P - 77570REQUEST FOR ELECTRICAL INSPEC i._
1� 817 � 0 6 9� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 '�},��..
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us �.���
Describ -iuing the b2ck of the white copy if ecessary - the wor vered b this request:
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GENERAL FEES Outdoor Li h'ng Standard @$1
SERVICES / POWER SUPPLIES Traffic S' nal Standard $5
0 to 400 Ampere na $25 Suoolemental Fee na $20
IALARM, COMMUNICATION, REMOTE CANTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Apparatus na. $.50
Lighting Retrofit @ $25 per Fixture
Center Pivot Irriaation Boom (�a $40
Special Ins ection a$.31 er Mile
THIS INSTALLATION MAY BE OI
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18170696
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiaative Fee
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(minimum total fee is $20) � o �
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I hereby certify that I inspected the elecVical installation desaibed he� �daf2s stateY
RWGH IN OATE
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FINALINSPECTION � DpTE
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3CONNECTED IF NOT COMPLETED WITHIN 12 MONTHS ____�
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Date: Rou h-in In
�� g spedion Required? Yes ❑ No Inspection Other Than Rough-In: � Ready NoW�Vill Call
�{—� 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 elecUical work at
Job Site SVeet Address Cit�r I^� �G
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Township Section Range Fire No. County
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Owner/Occupant Name Please Pro�ride Two (2) hone Numbers InGuding Area Code
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Electrical Utility EI I Utilit d ress
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ConVador / Company Name Contrador License Number Master Electriaan r Power Limited Technici
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Mailing Address (Contractor, C�p�ny or ner Perfortnin Installation j
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Authorized onVactor r e o ing Installatlon) Please Provide Two (2) Phane Numbers Including Area Code
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