P - 77617REQUEST FOR ELECTRIC L INSPECTI �`�
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1- 8 3�� 611 � Minnesota Board of Elect '' ��� n��'�"� � �
1821 University AveRUe Suit S-128, aint Paul, innesota 551 4 �
(651) 642-0800 T�'S'/MR� -627 3529 www.eleclricity.state.mn.us =��
Describe -using the back of the white copy if necessary - the work covered by this r uest:
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GENERAL FEES oor Lighting Standard $1
SERVICES / 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 Am ere $75 Transformers over 10 KVA $ 20
CIRCUITS / FEEDERS Transformer I Power Su I for Si ns I Outline Li htin $5
0 to 200 Am re $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere $10 Includes ihe Service and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CANTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUiTS OF LESS THAN 50 VOLTS Additional Ins ion Tri s$20
Each S stem Device or Apparatus @$.50 Investi ative Fee
ADDITIONS TO THE GENERAL FEES Reins ction Fee $20
MULTIFAMILY DWELLINGS PER UNI TOTAL FEE /� �
3 to 12 Units @$50 Per Unit (minimum total fee is $20) � L).
I herebv certiN that I insoeded the electncal inslallation described herein on the dates stated: I
Center Pivot Irrigation Boom �a
Manufactured Home Park Lots
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Se arate Bondin Ins ion $20 —' �' Z 3"' ��
S 'al Inspection $30 per Hour �x"'�°'"fl°`m°"EO - "'�
S ial Ins ection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rough-in Inspedion Required? ❑Yes �o Inspection Other Than Rough-In:�eady Now ❑Will Call
�� `���`� You must call the inspector when ready! Date Ready: ��1� ��f
I certify that I am the�LICENSED CONTRACTOR �OMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address C'
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Township Section Range Fire No. CO ,
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Own Occupant Nam Please P{ovide Two (2) P one Num ers in��,.,.�.y __�de
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Electri I Utility, _ ( Electrical UdlityAddress
> pany Name �' Contrador License Number Master Electrician or Power Limited Technician
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,s (ConVador, Company or ner rform�g Install tion� �
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�ture (Contracto wne o g Installation Please Provide Two (2 hon Numbers InGuding Area Code
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ON BACK OF YELLOW COPY BOARD OF EIECTRICITV COPY EB-00001A-75 8.1. 2004