P - 77655REQUEST FOR ELECTRIC L I P T ON -�
1� J��� 19 0� Minnesota Board of Electricity C������a� �, �
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 necessary - the work covered by this request:
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GENERAL FEES Outdoor Li hting Standard @$1
SERVICES I POWER SUPPLIES Traffic S' nal Standard $5
400 Am re $25 / Sup lemental Fee $20
401 to 800 Am re $� Transformers u to 10 KVA $10
Above 800 Am re $75 /" Transformers over 10 KVA $ 20
CIRCUITS I FEEDER Transformer I Power Su I for Si ns I Outline Li htin $5
0 to 200 Am re $5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere $10 Includes the Service andlor Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, OTE CO OL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LE VOLTS Additional Ins ction Tri s $20
Each Svstem Device or Aooaratus C� $.50 Investioative Fee
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighting Retrofd @ $.25 per Fi�ure
Center Pivot irriaation Boom (� $40
Fee a $20
TOTALFEE �r,,
iimum total fee is $201 ��. 3 u
I hereby certify that I inspeded the elecViral installation desaibed herein on ihe dates siated:
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FIIUL INSPECTION DA7E
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S �allns �on $30 rHour �Reornawoaam--
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S ial Ins ion $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITH
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Date: Rou h-in Ins
g pection Required? ❑ Yes �o Inspection Other Than Rough-In: eady Now ❑ Will Call
You must call the inspector when ready! Date Ready:
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereb request inspection of the electrical work at:
Job Site SVeet Address City
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Owner/Occupant Name Please Provide Two (2) Phone Numbers Induding
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Electrical UGlity Electrical Udlity Address
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Contractor / Company Name Contractor License Number Master Eledrician or Power Lim
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Mailing A dress (ConVador, Company or Owner Performing Instellation)
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Authoraed Signature (Contractor or Owner PerfomupaJpctalla6on) Please Provide Two (2) Phone Numbers Including
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INSTRUCTIONS ON BACK OP VELLOW COPY BOARf] OF FI FCTRICITV COPV - on_nnm