P - 77162REQUEST FOR ELECTRICAL INSPECTION ����'�
1� 814 � 3 2 3� Minnesota Board of Electricity k �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 `��
�� �� .� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us �a��
Describe -usin the back of the whit copy if necessary - the work covered by this request:
� 5 l - � `� ' gS�'
GENE L F ES Outdoor Li hting Standard @$t
SERVICES / POWER SUPPLIES Traffic Sianal Standard (o? $5
ALARM, COMMUNICATION, REMOTE CANTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
� Each Svstem Device or Aooaratus (o� $.50
Additional Unit @
Lighting Retrofit @ $25 per Fi�ure
Center Pivot Irtiqation Boom na $4(
Transformer / Power Su I for Si ns I Outline Li hti $5
NE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Insoection TriPS (� $20
(minimum totai fee is $20)
I hereby certify Nat I inspeGed Me electrical installation described herein on the dales stated: �
2 •zg'� I
S eciai Ins ction $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
--------__.��____��__��__.__--__�_�__—_._.-----�--------------� _�--- -----�%N � �_oJ� --
I III II III i iII II IfI II III II I�I iI III II III NNl l� _ o S
1 8 L 4 3 2 3 0 �� O
s � �
Date: Rough-in Inspection Required? ❑ Yes Ig�No Inspection Other Than Rough-In: ❑ Ready Now ill Call
��V� `\
You must call the inspector when ready! Date Ready:
I certi(y that I am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electricai work at
Job Site SVeet Address �� �� ' �� C� � � �
u r,
Township Section Range Fire No. County
�Y1D ��
Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
r��e PE � k- � rt5 6 s7� , 5a8� O
Electrical Utility _ Elechipl Utility Address
Anoka, I
� Mailing
lumber Master Electrician or Power Limited Technician
�/ License Number
t��
Please Provide Two (2) Phone Numbers
� I � �