P - 770001 (] REQUEST FOR ELECTRICAL INSPECTION -
I 1���J - 2 6 9 Minnesota Board of Electricity
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -
i (651)642-0800�fTY/MRS 1-800�27-3529 www.electricity.state.mn.us
Desciibe -using tlie badc of the white copy'rf oecessary - the wrork co��ered by tlNS request:
UPG-r�0�`� Srr�6r�c neT�c.���s,
SUPPLIES
Fee
�
over
200 $10 Includes tlie Service andlor Power Suppty up to 500 Amperes, All
)MMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit (a� $80
CIRCUITS OF LESS THAN 50 VOLTS A�itional I ' Tri $20
i Device or tatus a.50 Inves' tive Fee
ADDITIONS TO THE GENERAL FEES R' ' Fee Y20
ILY DWELLINGS PER UNI TOTAL FEE � /y �
! Units �$50 Per Unit (minimum total fee is $20) � CJ
1dd'd'I011al Unit � $25 Twsu�ncoaesrECronusEaav
OTHER ADDITIONAL FEES
g Retrofit (a� $.25 per Fixture i nereny cer�ir�r tnet I�spec�ed a�e e�cmcai i�taiianon desaibed herein on n�e da�es stated:
Lots
��-07
THt3 INSTALLATION MAY BE ORQERED DISCONNECTED IF NOT COMPLETED iMTMIN 12 MONTH3
ro� or-Fec :�s� or��r �/f/—
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�' Rou Frin In
/�7 g apection Required? ❑ Yes � jNo Inspectlon OUier Than Rough-In: ❑ Ready Pbw Wip Cap
f(f •`/ �� �/ You must call ttie inspector when ready! Date Ready:
I cerdfy thati am fhe �LICEN3ED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elactrical walc at
Job si6e street nddre� �;h,
�o�o Y St �" FR.►�L�Y
T���P SecUon Renge Fire No. Counry
l�%O K A-
�ve�� Name Pleaee Proviae rwo (2) Phone Nu�s �ndudirp nrea code
� rIC �bin5 �i b�221 �b8� ( )
••���w•��,��,•j�,�w r i wnuaaw �ro�iae nunmer mas[er trednaen or rower �Nrntea Tecnnician
C��ie�l l �/ G ��� G � � �i� �/�/� �5 `T �p License Number/� � , � ��
� - • r fN�l
MaiGng Address (Contradw, Campany or OT�vner Perfonning InslaYaUon) n
�.22�' LeQna V// �V':� �1J/ � I{�� ////�/� 7��'�
A nature (Contra or Owner Pe mg afallation) Please rovide Two (2) Phone Numbeis Induding Area Cade
�IY�-' �12)N90-8�i41 (�12.)5"Sy-706�
UCTIONS ON BACK OF YELIOW COPY BOARD OF ELECTRICITY COPY cw_mm�e_�s a��me