P - 762791 7 9-� 5 2 g I,j I �EQUEST FOR ELECTRICAL INSPECTION
� —�. Minnesota Board of Electricity i;
L- I 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� • (�651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.sta/e.mn.us
-using the back of the white copy'rf necessary - the work �vered by this request:
E��.EL EMERG'� SA+�FF+' S S!� I TCH
GENERAL FEES Outdoor Liahtina Standard lo� �1
CIRCUITS OF LESS THAN 50 VOLTS
III�b4l �III I
IIIIII�I��III� IIIIIIuIIIfIIIIUI
�7975293
Traffic Signal Standard
Suoolemental Fee (�a $
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amper�s, Ail
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Investiaa6ve Fee
TOTAL FEE ��tl �{�
total fee is $20)
I inspBCted the electrical instaVadon described herein an the dales s�ted: I
TED IF NOT COMPLETED WITHIN 12 MONTHS
REC'D JUN 14 2001
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�e� Rough-in Inspection Required? ❑Yes .❑ No Inspection Other Than Rough-In: �Ready Now ��II Call
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�,/ �, �, / Q j You must call the inspector when ready! Date Ready:
I certify that I am the [�7 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Sits Street Address City
4�5i s l!� S I �IE F�iT�LEYq hi�
Including
L�L�SHE�' q ,.Tt7E 1
Electrical Uti4ity
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coMrac[or I Gompany Name Contractor License Number Master Electrician ar P
HUi�T ELECTRIt:, CCI�iF'OFif�TTC�i;! C� ����J LicenseNumber
IylaiGng Address (Contractor, Company or Owner Performing Installation)
�.�oa TE�iRITOfiT�1L Ft�i�I�9 s��n�i ���u�9 ��� 5����
Authorised Signeture (ConVactor or Owner Perfortning Installation) Please Provide Two (2) Phone Numbers
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