P - 76554_�, REQUEST FOR ELECTRICAL INSPECTION .� �
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1����- 913 � Minnesota Board of Electricity ;�-
1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104 �,
(651) 642-0800 TTY/MRS 1-800-627-3529 www.elECiricity.state.mn.us
Descnbe -using the back of the white copy if necessa the work covered by this request:
E?CC�L rhlc.hCiY S�UkR'S St�iTtwH
GENERAL FEES Outdoor Lighting Standard @$1
SERVICES I POWER SUPPLIES Traffic Sional Standard (a� $5
0 to 400 Ar
401 to 800
Above B00
0 to 200
K
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighti Retrofit @ $.25 per Fixture
Center Pivot Irripation Boom na $40
Supplemental Fee @ $20
Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
Transformer I Power Su I for Si ns I Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Inciudes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Investigative Fee
Reinspection Fee
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total fee is $20)
I hereby certify that I inspected the elecUical installation descnbed herein on the dates stated:
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Special Inspection @$30 per Hour exaiReo; nenNOONeo onre
Special Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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I°`°' I Rough-in Inspection Required? ❑ Yes �f No i Inspection Other Than Rough-In: [,�Ready Now ❑ Will Call
I�_ �' �`'���� ___ LYou must call the inspector_when ready! _ �Date Ready:
I cerGiy that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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I Job Site Street Address � City ��, Z�+_ �� ��
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P � � �, Seciion 'i, Range j Fire No. . County
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� Owner/Occupant Name i lease Provide Two (2) Phone Numbers Including Area Code
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! Electrical Utility , Electrical Utility Address
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� Coqlractor / Company Name Contractor License Number i Master Electrician or Power Limited Technici
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i HUh1T ELEGTi;IC i'ORF'��f,ATTC�h! � t'�� t3�t38:'.� ,��censeN�mber
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'. Mailing Address (Contractor, Company or Owner Performing Installation)
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9 � 9 � ) Please Provide Two (2) Phone Numbers Including Area Code
AuthO� Si na� ntrec[or or Owner Performin Installation �� I�$ 5� h�$+L ��� � �
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IN$TRUCTIONS ON BACK OF YELLOW COPY eOARO nF FI FcTRicirv r.nav �o ����,,, ,� o...