P - 76088REQUEST FOR ELECTRICAL INSPECTION
1�( v�- 3 8 9❑7 Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
.^ (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.sJate.mn.us
DESCribe -using tha back of�l� white cessary - the wo vered by this request:
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GENERAL FEES Outdoor Liqhtinp Standard (�a. $1
OF LESS THAN 50 VOLTS
�ce or Apparatus @ $.50
iIONS TO THE GENERAL FEES
tinnal Unii
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Boom
ONE & TWO FAMILY DWELLINGS, EACH UNR
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ction Tri @ $20
Investigative Fee
Reinspection Fee @ $20
TOTAL FEE
(minimum total fee is $20) p�d
THIS AREAFOR PlSPECTOR I1SE ONLY
I hereby certify fhat I inspected the e�ectrical instsllation described herein on the dates s�ted:
ROUGH IN �'�
� ��,� i� - /n - ia �-�
BE ORDERED DISCONNECTED IF
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17843897
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MONTHS
�� Rough-in Inspection Required? ❑Yes �No Inspection Other Than Rough-In:�2eady Now �Will Call
6„1� You must call the inspec[or when ready! Date Ready:
I c�tify �at I am the CJ I,�CENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Nartie
Numbers Inciudinp Area
. N/A 7C
C04traciw � Company Name Contractor License Number Master ElecVician or
�OV�m a�TC ** n ^,��� License Number
r.�ru�ia�a a.i.�i a.rw.�
Maiqrtp Addres4 (Contractor, Company or Owner Performing Installation)
23Qd9 eaaaa�V�D ST Nw ST FRANQ3 N.QV SSb7�
R�{,hn� S que (GonVactor or Ovmer Perfo in tallation) Please Provide Two (2) Phone Number
" " �/63 �53-5731 �63-:
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