P - 76292Q ° FtEQU�ST FOR ELECTRICAL INSPECTION �` �
1� 7,.7 7- 5 3 2� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
' • (651)642-OSOOTTY/MRS 1-800-627-3529 www.electricity.state.mn.us
-using tl�E back of the white copy if necessary - the work covered by this request:
� E�GEL EidEi;GY S�tVEF;'S St�IT�,N
IRLARAA, COMMUlVICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
to 72 Units (Q1$50 Per Unft
Hour
FEES
Traffic Sipnal Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circutts and Two Inspection Trips Each Dwelling Unit @$80
ALLATION MAY BE ORDERED DISCONNECTED IF
II�I�IIIIIIIIIIIII�INIIIII���I�I i�ll
�797532
TOTAL FEE I .,� ��
total fee is $201
that I inspected the el�trical installaUon deacribed herein on the dat� stated:
� �� �—�
ETED WITHIN 12 MONTHS
RECro J U N 14 2007
�oo �- ��o��
�e� Rough-in Inspection Required9 ❑ Yes � No Inspecdon Other Than Rough-In: �Ready Now ❑Will Call
�T� �. �. i d� You must call the inspector when ready! Date Ready.
i certify that I am the �I LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
.lob Site Street Address c�y F�' I D L E Y q (�I i�l
i4E�S e�4TN r��lE i�E �
�
Tawnship Sectlon Range Fire No. Cou °-
Owner/Occupant Name Please Provide Two (2) Phone um re Including Area Code
HC1LL 7 STEF: q pGRO�'NY M ( � ( �
E�:Ctricel UGlity Electrical UUlity Address
'.�i��� E�t���1Ci
Contractor / Company Name Contrector License Number Master Electrician or Power Limited Technician
License Number
HUi�i ELE� Tf;IC COR�'OF.AiIOhf CA C1+Jd�f�
M@iling Address (Cnntractor, Company or Owner Perfortning Installation)
�34ti TERRITO�;TAL F:O�1D9 �(all�lT F'�'iUL9 I�ha ��511E?
Authoriasd Signature (ConVactor or Owner Perfortning Installadon) Please Provide Tvro (2) Phone Numbers Including Area Code
�55� 64�—�511 � �
INSTRUC110N3 ON ACK 6F YELLOW COPV BOARD OF ELEGTRICITV COPV FA-flnnmA-95 N � 7(m4