P - 77699REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electria �� �_ � ��
1 6 41-112 6 182, ��;�e�;� A�e��e S�;,e S- 28, S t a� in �ota 5 10
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
❑ NEW ❑ REMODEL 0 AD TION EPAI Describe -using the back of the white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoor Li hfin Standard $1
S�RVICES I POWER SUPPLIES � Trafic Sian� Standard � S5
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or aratus E.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Li htin Retrofit $.25 er Fi#ure
Center Pivot Irri ation Boom $40
ManuFactured Home Park Lots � 825
I�il Ilill IIIiI (iill IIIiI IIIIIIIIII IIIII �� I�I
1641L12�
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Paxer Supply up to 500 Amperes, All
Circuifs and Two Inspection Trips Each !axelling Unil @$BO
TOTAL FEE I
(minimum total fee is $20) —"�`
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I hereby cer6ry thal I inspected the electrical installa6on described herein on ttie dales sia0ed:
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f COMPLETED WITHIN 12 MONTHS _ �
K u�: ua[e:� �^ Roughin Inspectlon Required? ❑ Yes ❑ No Inspedion Other Than Rough-In: �eady Now ❑ YVfll Call
G� You must call the inspecta when ready! Date Ready:
I oertify that I am the ICENSED CONTRACTOR ❑COMWANY ❑ OWNER and hereby request inspection of the elecfiral work at:
Job Sit� �O �Stree�,� ' ��R� �' � ' City /� Tp Cod�
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Sedion Township Range Fire No. ty
Owner/Occupant Name . Please Provide T� ) Ph ��ber(� uding Area Code
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�ver Supplier Power Supplier Address
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Sa/ CompV LNem� Contract� License Numl
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ling Address (Contraqw, Company or Owner orming InsiallaUon) '/�
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License Number
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INBTRUCTONS ON BACK YELLOW COPY BOARD OF ELECTRICITV COPV T- EB-OppOlp-1d 8.1.2002
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