P - 81837REQUEST FOR ELECTRICAL INSPECTION
�" � � � O � , � Minnesota Board of Electricity
_� U � '_ �` 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
. �� (651) 642-0800 TTY/MRS 1-500-627-3529
www.electricity.state.mn.us g��
Identify the work covered by this request: r�� N�,2-+�. �( —�,%�, � w� 0�� fJ �
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EW ❑REMODEL ❑ADDITION ❑REPAIR /�iv� CQN' �JV o t L
GENERAL FEES Outdoor Li htin Standard �$1
SERVICES / POWER SUPPLIES Traffic Si nal Standard �$5
0 to 400 Am ere �$25 Su lemental Fee �$20
401 to 800 Am ere �$50 Transiormers u to 10 KVA �$10
Above S00 Am ere �$75 Transformers over 10 KVA �$20
CIRCUITS / FEEDERS Transformer / Power Su I for Si ns / Outline Li htin �$5
0 to 200 Am ere �$5 e O ONE & 1W0 FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere �$10 Includes the Service andlor Power Suppty up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circufts and Two Inspection Trips Each Dwellin Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additionai Ins tion Tri s�$20
Each S iem Device or A aratus �$.50 Investi tive Fee
ADDITIONS TO THE GENERAL FEES Reins ection F�e �$20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE
3 to �2 Units �$5o Per Unit (minimum total fee is $20) �%'�
Each AddRional Unit � $25 �"'"s�`�" �E °'°`v
OTHER ADDITIONAL FEES
Li hdn Retrofit �$25 r Fixture
CeMer Pivot I' ation Boom �$40
M2nUfaCtufBd H0�12 Pafk LotS �$25 I hereby ce' that I inspected the electdcal installaUon destxibed Irerein a� 1he dates sta�d:
Recreatlonal VehiGe Park Sites �$5 w-
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Se arate Bondin Ins ion �$20
S ial ins ection �$30 r Hour °�'�
S ial Ins �on �$.31 r Mile 6^ 7—�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED T COMPLETED WtTHIN 18 MONTHS
FOR OFflCE USE ONLY
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Request Date: Rough-in Inspection Required? ❑ Yes o Inspection Other Than Rough-In: ❑ Ready Now WHI Call
s-� ��-E/ t You must call tlie inspector when ready! Date Ready:
I ceRi(y that I am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of Uie electrical work at:
Job Address (Street, Box, or Route No.) City
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Section Township Range Fire No. Counry
30 � �� �9No�R
Occupant Phone
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Power Suppli r Addre
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E rical CoMractor / Company Name CoMrecror License Number - Master License Number
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Mailing Address (ConVactor, Company or Owner Performing Installation
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Authoriz ignature (� y or Owner Perfortning Installat�V V/�� Phone
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E&00001A-13 iM2000 BOAHD OF ELECTRICRY COPY INSTAUCiIONS ON BACK OF YELLOW COPY