P - 78209REQUEST FOR ELECTRICAL INSPECTION
1� J��- 515 4❑ Minnesota Board of ElecUicity -
^ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electriciry.state.mn.us
❑ NEW EMOD L❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
�1r�fi-�cw(, �,- ba,se,w,�-�rush, ��cl��ate, er�cf�`c �u..�et, l�F/C�gr.-��c.
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE �ENERAL F
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit ' �
Each Additional Unit @ $25 '
Center Pivot
� THIS INSTALLATION MAY BE ORI
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15305154
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Su lemental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transiortner / Power Su I for Si ns / OuUine Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unil @$80
Additional Ins fion Tri $20
Investi ative Fee
Reins tion Fee $20
TOTAL FEE
(minimum total fee is $20) �7�
iNIS AREA FIXi INSPECiOR 115E Wlv
I hereby certiry that I inspected the electrical installation described herein on the dates stated:
IF
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Request Dffie: � Rough�n Inspection Required? � Yes ❑ No Inspection Other Than Rough-In: �Ready Now �1 Will Call
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�^��- � y You must call the inspector when ready! Date Ready:
I certify that I am the �I.LICENSED CONTRP�� ANY ❑ OWNER and hereby request inspection of the electrical work at::
Job Site Address (Street Box, or Route"�.), Ci�� .. Zip Code�y��
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Sedion Township�� Ra� � Fire No. CountM �
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Owner/Ocw nt Name Please Provide Two (2) Phone Number(s) Induding Area Code
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or Owner Pei
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ConVactor License Number Master EJecVician or P
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EB-OOOOtA-14 8.1.2002