P - 79097` ' REQUEST FOR ELECTRICAL INSPECTION � `
1' 6 5 0- 7� 6� Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0600 TTY/MRS 1-800-G27-3529 wrvw.electricity.state.mn.us
❑ NEW�,.)O REMODEL ❑ ADDITION q REPAIR Describe-using the back of the white copy if necessa�the work covered by this request:
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GENERAL
Fee
�
over
Above 200 Am ere $10 Includes the Service andlor Power Suppiy up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Uoit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additinnal Insoec:tinn Tnos � S?0
Retrofit
PER UNIT TOTAL FEE � t—
unit (minimum total fee is $20j ,� � � J�
�5 .ws naFn Faa ir�craa usE onxr
I hereby certify that I inspected the elec4ical insfallation described herein on tl�e d�es sWEed:
: ADDITIONAL FEES �� �„` :.� � �� � ��"
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I IIII Il I!I II III II (II !! I II II ili II Ili II III ��i i I�
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16507865
I certiiy lhat I
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Rough-in Inspe�tion Required? ❑ Yes InspeGion Other Than Rough-In: y Now 0 Wdl Call
You must catl the i�spectar when readyl �te Ready:
NSED CONTRACTOR ❑ COI�ANY ❑ OWNER and herEby request mspection ot the elechical work at;:
aoaress (s'treet eo� a R� rw.} G7(y �
1 �
Towns �P Ra�ge Fire No.
ocuPent Narne `
i �
i ier supp• Address
11967 Eidorado Street NE, _� �
PeAorming Insfa6etion)
763) 786-8484
d nadue (ConVactor y a ing InstaMation)
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ON BACK Oi COPY BOARD OF ELECTRICITY COPY
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n�as� r.recviaan or
License IJ�nber
EB-00001M1� 8.1. ZOQ2