P - 78467c� REQUEST FOR ELECTRICAL INSPECTION
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1�..T 1 6� 7 g O 1 Minnesota Board of Electricity ,- ;
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 :. '
` (651) 642-0800 TlY/MRS 1-800�27-3529 www.electricity.state.mn.us ' ""'`
❑ NEW ❑ REMODEL ❑ ADDITI ❑ REP IR Describe -usin the back of the white copy if necessary - the xrork covered by this request:
SERVICES I POWER
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus � 5.50
3to12
Center Pivot
IIIiI II III II III III� �III II III il�l II� a� I�.
15167901.
Traffic Si nal Standard $5
Su demental Fee $20
Transfortners u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su fw Si ns I OuUine Li hGn $5
ONE & TWO FAMILY DWELLIN6S, EACH UNIT
Includes ihe Service andlw Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
TOTALFEE
(minimum total fee is $20) �� • S�
TH5 AREA FOR INSPECTp21SE OKY
I hereby certify Mat I inspecled tlre elecfical instaY�on de�ibed herein on Me da�es s�ed:
�- — — � 2rj'rQ1
OATE
COMPLETED WITHIN 12 MONTHS
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0?4� SO
Req}uest Date: Rough-in Inspection Required? ❑ Yes ❑ No I�pediwi Other Than 12ough-In: y Now O 111fi11 Call
/ O' � 3 You must call the inspeclar when ready! Date Ready.
I certify that I am the LICENSED CONTRACTOR ❑COA�PANY ❑ OWNER and hereby request inspection of the electrical work at:
J� Address iSt Box� ar� No.) � City Zip Code
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IN87RUC710N8
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Please Frovide Tero (z) R,one ra,mner(s) x,auarg nrea code
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�se Nunber Master �ectriden or Pow� Laniled T ician
License Number
Phane (s) ` /��
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E&00007M14 8.7.2002