P - 76428/� REQUEST FOR ELECTRICAL INSPECTION ��`�•
2� 0��F �"� 5 6 5� Minnesota Board of Electricity k. :
� 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 /t �white copy if necessary - the work covered by this request:
O � l� C��UJO ✓1 ( ' � � � ' � �S
GENERAL FEES Outdoor Li hting Standard @$1
SERVICES / POWER SUPPLIES _ Traffic Sipnal Standard a(� $5
401 to 800
Above 800
CIRCUITS I FEE
IMMUNICATION, REMOTE CONTROL,
CIRCUITS OF LESS THAN 50 VOLTS
�vstem Device or Aooaratus (� $.50
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Units @$50 Per Unit
Each Additional U�it @ $25
OTHER ADDITIONAL
Lightin Retrofit $.25 per Fixture
Center Pivot Irriaation Boom C� $40
Special Inspection $30 per Hour
Speciai Inspection $.31 per Mile
THIS INSTAL6At10�N MAY BE ORDERED
I IIII (I III I) ��) I) (II (I ��� (I III II III II III �� (�
� 0 2 4 5 6 5 Q
Transformer / Power Su I for Si ns / Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ection Tri s $20
Investigative Fee
Reins ection Fee $20
TOTALFEE
(minimum total fee is $20) Q �
THIS AREA FOR INSPECTOR USE ONLV
I hereby certi(y that I inspected the electrical installation described herein on the dates stated:
0
�EC.TED JF NOT COMPLETED WITF
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Date: Rou h-in Ins ction Re uired? ❑ Yes N� In
9 PB q spection Other Than Rough-In: ❑ Ready Now Will Call
��l3 �V � You must call the inspector when ready! Date Ready:
I certify that I am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site SUeet Address Cjh,
5 �ig u � rid�
Township Section Range Fire No. Coun
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Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
`o �e,rv� bC � E76� S � ( -��7� )
a' "�"`Y Centerpoint En �I�
2 Centi e r
x°``�°`"�"y `�oka, MN 55304
7s3-757-6202
Address (Contractor, Campany or Owner Performin�
License Number Master Elactrician or Power
/1 1 �'1 ri � License Number
Please Provide Two (2) Phone Numbers Including Area Code
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