P - 76581REQUEST FOR ELECTRICAL INSPECTION �
1� 7 8 1� 9 O 1 2 Minnesota Board of Electricity ;�4,` �'
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
(651) 642-0800 TTY/MRS 1-800-627-3529 wia�w.electricily.slate.mtt.us
ribe -using the back of the white copy if necessary - the work covered by this request
E�[:k?. �}�E��;Y SAVFR'S S�JIiCH
GENERAL FEES Outdoor Lighting Standard @$1
✓ICES I POWER SUPPLIES Traffic Signal Standard @$5
0 to 400 Am ere @$25 Supplemental Fee @$20
401 to 800 Am ere $50 Transformers u to 10 KVA $10
Above 800 Ampere (cil $75 Transformers over 10 KVA (� $ 20
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Ap�aratus (� $.50
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
Additional Inspection Trips @ $20
Investigative Fee
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER AODITIONAL FEES
�i htin Retrofit $.25 per Fixture i nereby certih
Center Pivot Irrigation 800m @$40 ft01GH1N
Manufactured Home Park Lots $25
Recreational Vehicle Park Sites $5 F�Na��NSPec,�oN
Se arate Bondin Ins ection $20
Special Inspection @$30 per Hour exP�Reo; nenNOc
Special Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF
IIII II I� II I� II I� II I� II � II �I II I�I II I� I�II
178L9012
TOTALFEE ��6��
total fee is $20)
ihat I inspected ihe electrical installation descnbed herein on �he dates stated:
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LETED WITHIN 12 MONTHS
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ua[e: � Rough-in Inspection Required? ❑ Yes ;�] No � Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
I� �' ff 'i" �� t�� You must call the inspector when ready! � Date Read
Y
i certify that I am the � LICENSED CONTRACTOR ❑ COMPANY O OWNER and hereby request inspection of the electrical work at:
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� Job Ske tre t Address - � � � � � �
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Range I Fire
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�IOwner/Occupant Name ' Please Provide Two (2) Phone Numbers Including Area
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�I Electrical Utility ', Electrical Utility Address
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Contractor / Company Name � i Contractor License Number Master Electrician or Power Limited T
�' �I.NT ELEGTF{Its C[7FiF'QRrCIIJN ' GA ,.tJS�,,''s ��eN°r"be'
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Mailing Address (Contractor, Company or Owner Performing Installation)
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Authonzed Si nature (Contractor or Owner Performing Installahon) �I Please Provide Two (2) Phone Numbers Including Area
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INSTRUCTIONS ON BACK OF YELLOW COPY BOARD OF ELECTRICITY CC�PY ro nnnn� e. � a