P - 76583REQUEST FOR ELECTRICAL INSPECTION �
1����- 9 2 6 9 Minnesota Board of Electricity ,�-r ,�
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 - -
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy if necessa - the work covered by hi re est:
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ERVICES I POWER SUPPLIES
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aqoaratus (� $.50
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
lighting Retrofit @ $.25 per Fixture
Center Pivot Irrioation Boom (a� $40
Outdoor Liahtina Standard
Supplemental Fee @ $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns I Outline 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 Unit @$80
Fee
Fee $20
TOTALFEE .'�y.(�a(j(�j
nimum total fee is $20)
that I inspected the electrical installation descnbed herein on the dates stated:
Se arate Bondin Ins yction $20 V �—�--^--- '—�j� d 6
Sp2d21 IOSpection $30 pB� Houf exaiaeo neaNOONeo onTe
Special Inspection $.31 per Mile
TH18 INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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I V�e� I Rough-in Inspection Required? ❑ Yes
�[] No �, Inspection Other Than Rough-In: �Ready Now ❑ Will Call
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�__ __ You must call the inspector when ready! I Date Ready:
I certify that I am the L] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
I Job cite Street Address __ T _ _ — — . _ __ . - _— - _ __- - CitY F i� I D � � Y �( M
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OwnedOccupant Name . - I -�- -� I — �
-�Please Provide Two (2) Phone Numbers Inclu�
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Electrical Utility � - � ��, Electrical Utility Address
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I Contracta / Company Name �I Contractor License Number Master Electrician or Power
: �'i��� F'LkGTRIG ����F���{��i��� iv�°y �Q}��j ILicenseNumber
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I Mailing Address (Contractor, Company or Owner Performing Installation)
I t�(30 TEF�RI [Gf�II�!_ RGM.�, Sf�I�IT F'ALIL_e MN 5��1j.�
I Authorized Si nature (Contractor or Owner Performing Installation) ' Please Provide Two (2) Phone Numbers Incluc
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INSTRl1CTIONS ON BACK f]F VFI I nW Cf)PV anaan nc F crTOi�irv rnov