P - 80040REQUEST FOR ELECTRICAL INSPECTION
Minnesota Soard of Electricity
' 1-396-111 � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 ?TY/MRS 1-800-627-3529
www. eiectrici ty. sta te. mn. us
Identify the work covered by this request:
O NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR
�
Above 200 Am ere � $10
ALARM, COMMUNICA710N, REMOTE CONTROL, SIGI
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or aratus �$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI�
3 to 12 Units �$50 Per Unit
Each Additional Unit � $25 ,� � �
XCEL ENERC�Y SAVER'S SW{TCH
�o
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$i
Additional Inspection Trips � $20
1L FEE
is $20)
FOq INSPECTOR USE ONLY
I hereby certity Mat I inspected the eleclrical instellaNOn described herein on Me dates stated:
HOUGHIN DATE
FINAIIN . � DATE
� � � 0�
1 1E.�l.QIS�Si�1PlE7�Q�NITHIN 98 MO TI�HS
FOR OFFICE USE ONLY
I II�III II�I II� I�II� IIIII ��� �III �I �III I��I T!-' /
* 1 3961 1 1 5* �S�
Reque Rough-in Inspection Required? ❑ Yes o Inspectlon Other Than Rough-in: Ready Now ❑ Will Call
You must call the inspector when ready! Date Ready:
I ceRify that I am the � LICENSED CONTRACTOR L�`COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Address (St�, Bo�� r����, NE 01y FRIC�I.EY zip °ode 55�f32
Section Township Range Fire No. County
���T Rnu� w 9 � 4 j Ph�
Power Sa�olier ��Y Address ,�
2�tL
Electri�����,�,����T�QN Contrector Lic�eIlly�yq0� Master License Number
4A Wat1
Mailing ,9dtlr�ss ���ny„Q�,qy�; p�rfwmioa�� I tio�M 55114
L3t10 hi(.7AU AIIYI-
Authariz ' nature (C�tracto mpe�or Owner Performing Installation) Phone �, ���,
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EB-OOOOtA-13 71112000 BOARD OF ELECTRICITY COPY '., INSTRUCTIONS ON BACK OF YELLOW COPY
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