P - 77306REQUEST FOR ELECTRICAL INSPECTION �����
1' 8 3 9� 9 51 � Minnesota Board of Electricity ��� ���
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �.
(651) 642-0800 TTY/MRS 1-800-627-3529 wxnv.electriciry.state.mn.us �,��
Describe -using the back of the white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoor Lighting Standard @$1
SERVICES I POWER SUPPLIES Traffic Si nal Standard $5
• 0 to 400 Ampere $25 Supplemental Fee $20
401 to 800 Am re $50 Transformers u to 10 KVA $10
Above 800 Ampere (a� $75 Transformers over 10 KVA (� $ 20
I ALARM, COMMUN�CATION, REMOTE CONTROL
� CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Apoaratus (� $.50
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
FEES
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irriaation Boom fa� $40
THIS INST,
Hour
Mile
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Fee
Fee
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total fee is $20) � ai
thal I inspeded Ne eledrical installation described herein on the dates stated: �
.LATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTH:
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° Rough-in Inspection Required? ❑ Yes �No Inspection Other Than Rough-In: Rl Ready Now ❑ Will Call
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You must call the inspedor when ready! Date Ready:
I cert'rfy that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Street Address ��y
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Township Section Range Fire No. Coun
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OwnedOccupant Name Please Provide Two (2) Phone Numbers Including Area Code
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Electrical Utility Electrical UtilRy Address
/ Company Name Conhactor License Number Master Electrician or Power Limited Technician
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iress (Contractor, Company or Owner Performing Installation) �
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A ignature (C ntr r Owner Performing Installation) Please Provide Two (2) Phone Numbers InGuding Area Code
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INSTRUCTIONS ON � OF YELLOW COPY BOARD OP ELECTRIGTY COPY FB-00001A-15 n � �nna