P - 77526REQUEST FOR ELECTRICAL INSPECTION �
1� 7 8 7� 9 0 8 � Minnesota Board of Eiectricity ,�;-
, 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -
(651) 642-0800 TTY/M RS 1-800-627-3529 ivti�w. electriciry. state. mn. us
Describe -using th�back of the white copy if ne�s$�y.: �the wcuk,rqvere�,bythH rQqu�t; ��� �'_ ��
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GENERALFEES
/ POWER
ALflItM, GUMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @ $50
5 per Fixture
Boom @ $4C
'a�k Lots kil $
FEES
Outdoor
Supplemental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Tri s $20
Investigative Fee
Reins ection Fee $20
TOTALFEE t,jzi�:;�
(minimum total fee is $20)
THIS AREh FOR INSPECtOR tISE ONLY
I hereby certify that I inspected the electrical installation described herein on the dales stated:
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5�8Gt21 IfiSp2C110f1 $� �� HOUf � FxaiaEO: AenuoonEO � oaTE
Spscial Inspection @ $.31 per Mile
THiS INSTALl.AT10N MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Rough-in Inspection Required? ❑ Yes �] No � Inspection Other Than Rough-In: [�Ready Now � Will Call
You must call the inspector when ready! I Date Ready:
I certlty that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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dob Site Street Address _ _ __ �_ - - -
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� Township ��, Section TRange - ,' Fire No. II County
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COWnedOecupant Namet� � I Please Provide Two (2) Phone Numbers Including Area Code
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Eleci('ncal Utili� ry_ � �Electrical Utility Address �
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'i ContraCtor / Company Name Contractor License Number - � Master Electrician or Power Limited Technicia�
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Matu�g Address (Contractor Com any or Owner Performin Installation�
[�.'..Yiett t�j,'; '7 �'�i i r t t 9 r_ � r. i
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�� A. ized Si nature (Contractor or Owner Performing Installation) � '�. Please Provide Two (2) Phone Numbers Including Area Code �
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�N$jRVCT10NS QN BACK OF YELLOW COPY � BOARD OF E1�CTRICITY COPV � co nnnn, �,� e, ..,.,,.