P - 77538, �, REQUEST FOR ELECTRICAL INSPECTION ��
1 ���� 4 9 7� Minnesota Board of Electricity �- : I
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
(651) 642-0800 TTY/MRS 1-800-627-3529 wwtiv.e[ectriciry.state.mn.us ,
Describe -using the back of the white copy if necessary - the work covered by this request:
�Sa.� �c� e c. �
GENERAL FEES Outdoor Lightin Standard @$1
SERVICES / POWER SUPPLIES Traffic Signal Standard $5
0 to 400 Ampere $25 Supplemental Fee $20
401 to 800 Amcere a�. $50 Transformers u to 10 KVA $10
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A paratus a$.50
ADDITIONS TO THE GENERAL I
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEE:
Liahtinq Retrofrt (a? $.25 per Fixture
I :
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
Add'Rional Ins ection Tri s $20
Investi ative Fee
Reins ction Fee $20
TOTAL FEE /�
(minimum total fee is $20) �,!
TMIS AREA FOR INSPECTOR USE ONLV
I hereby certi(y that I inspeded the elechical installation desaibed herein on the dates stated:
aoucHiN onre
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FINALINSPECTION DATE
PIRE01 �ONED �ATE
ction @$.31 per Mile � � �'*� �Z —Z 7' °�C
.LATION MAY BE ORDERED DISCONNECTED IF
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18204974
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Date: Rough-in Inspection Required? �es � No Inspection Other Than Rough-In: � Ready Now �II Call
��' �7 �� You must call the inspector when ready! Date Ready:
I certify that I am the �ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job SRe Street Address City
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Township � O Section Range Fire No. County
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OwnedOccupant Name Please Provide Two (2) Phone Numbers Including Area Code
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Eledrical Utility Electrical Uti ddre
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Contrector / Company Name Contrador License Number Master Electrician or Power Limited Technician
License Number
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Mailing Address (Contredor, Company or Owner Perfortning Installation) " •
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Author' SignaW Contra r or Owner Perfortning Installation) Please Provide Two (2) Phone Numbers Including Area Code
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INRTRI ICTInNR ON RACK OF VF1 1 0W C(]V V BOARD OF ELECTRICITY COPY E8-00001A-15 8.1. 2004