P - 76046REQUEST FOR ELECTRICAL INSPECTION
1� 7 8 7� � 7 2 � Minnesota Board of Electricity •;
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mtt.us
DesCribe -using the back of the�vhite copy'rf ne���,e ��,byk�i�r�t> 5 SW I TCH
GENERAL FEES Outdoor Lighbng Standard @$1
S�RVIGES / POWER SUPPLIES Traffic Signal Standard @$5
0 to 400 Am re $25 Supplemental Fee @$20
� 401 to 800 Am re $50 Transformers u to 10 KVA @$10
Rbove 8Q0 Amoere a(� $75 Transformers over 10 KVA na $ 20
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Apparatus @ $.50
ADDITIONS TO THE GENERAL FEES
Pivot Irrigation Boom
Includes the Service and/or Power Supply up to 500 Amperes, All
Circufts and Two Inspection Trips Each Dwelling Unft @$80
Additional Ins ction Tri $20
Inves6gative Fee
Reins ction Fee @ $20
TOTAL FEE � o ,.
(minimum total fee is $20)
THISAREA FOR PISPECTOR USE ONLY
I herebvi certifv that I insoected the electrical inspllation described herein on the dates stated:
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TFOPI AAAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIPI 12 MONTHS
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�� Rough-in Inspection Required? ❑Ye �] No Inspection Other Than Rough-In: �Ready Now ❑Will Cell
s r�.'� %0 � You must call the inspector when readyl Date Ready:
I c�rUfy that I am the C� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
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Ovmer/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
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Ca�trattor / Company Name Contrac[or License Number Master Electrician or Power Limi[ed Technician
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A�har7�ed S re(Contractor or Owner Performing Installation) Please Provide Two (2) Phone Numbers Including Area Code
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