P - 764731-787-941 2❑
IDeseribe -using ihe back of the white copy
GENERAL
IER SUPPLIES
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity ��- `
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -
(651)642-0800TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
�_ the �rar cquer?�l,bY�i,� 4g4�€,$�: .v: c�� .0 I i;= j�
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Outdoor Liphtinq Standard na $1
0 to 200 Am ere $5
Above 200 Am re $10
AIAR�A, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
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 @$80
Each System Device or Apparatus @$.50 Investigative Fee
ADDITIONS TO THE GENERAL FEES Reinspection Fee $20
fIfAMILY DWELLINGS PER UNIT TOTAL FEE "+, !_,t, j
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3 to 12 Units @$50 Per Unit (minimum total fee is $20)
Each Additional Unit @ $25 �NisnRenFOainsaecroauseoN�v
OTHER ADDITIONAL FEES
L� htin ReVOfit $25 pef FixtUre I hereby certify ihat I inspected the electrical installation described herein on the dates slated�.
Center Pivof irri tion Boom @$40 Ro��" �" DATE
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites $5 F�NA� �NSPec.�oN DATE r�
a{ate Bnndin Ins ection $20 -' �/
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Ci21 InSpeCYion @$30 pe� Hou� exaiaeo nenNOONeo onre
S ial Ins ction @$.31 per Mile
$ MISTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
IIII II III II �� II HI II IN II III II III I! III II I!I I Illi
171�79 41?
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� ��te� i Rou h-in Ins ection Re uired? ❑Yes I
g p q �.] No , Inspection Other Than Rough-In: �Ready Now ❑ Will Call
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I You must call the inspector when ready! _1Date Ready:
I I cerUfy that I am the 0 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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, Job Site Street Address I Cit I' �
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Owner/Occupant Name i Please Provide Two (2) Phone Numbers Including Area Code
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� Electri`a{ UtNity _ I Electrical Utility Address I
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': Contractor! Company Name � Contractor License Number Master Electrician or Power Limited Technician
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! Alaili ltddress Contractor Company or Owner Performiny Installation, r
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�A�W qed ' naturo (Contractor or Owner Performing Installation) �Please Provide Two (2) Phone Ni
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