P - 76270° �EQIdEST FOR ELECTRICAL INSPECTION
1���� _� 5 4 6 � 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.state.mr�.us
Describe -using the back of the whfte copy if necessary - the work covered by this request:
E�CCL ENE�:GY SAI�E�'S 5L�lI i GN
GENERAL FEES Outdoor Liahtina Standard C�a. $1
IMMUIdICATION, REMOTE CANTROL,
CIRCUITS OF LESS THAN 50 VOLTS
to 72 Unfts @$50 Per Unit
Lots
TH1S 1111$iALLATION MAY BE ORDERED I
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II�I IIIII IIIII IIIII IIIII IIIII �lll II�I 1� III�
17975467
Transformers up to 10 KVA @$10
Transformers over 10 KVA C� $ 20
Includes the Service andlor Power Supply up to 500 Amperes, All
Cirouits and Tvro Inspection Trips Each Dwelling Unit @$80
Additional Inspection Tdps @ $20
Investigative Fee
Reinsoection Fee l�a $20
total fee IS $20) � ��° ��
electrical installaation described herein on the da0es s(a�: I
�NNECTED IF NOT COMPLETED WITHIN 12 MONTHS
REC'D � UN 14 200�
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�Vtl"'' Raugh-in Inspection Required? ❑ Yes �] No Inspection Other Than Rough-In: [�Ready Now ❑ Will Call
g� ���� �' You must cail the inspector when readyl Date Ready:
I cerUfy tMat I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Sits Street Address c'ty F F: I?L F 1 q h1 i�l
'�9 b�TH l��Y i�E
6wngdOccupant Nama Please Provide Two (2) Phone Numbers Inclu�
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El,eckiCal Udlfty Electrical Utility Address
,�CEL EhiEFiliY
Cantracinr / Compeny Name Contractor License Number Master Electrician or Power
HUhi I ELEC7F:T� GC�RF'i]Fi�TTCif�1 i,� t���'u,� Lf�nseNumber
iulailirtg Address (Contrador, Company or Owner Perfortning Installation)
�3c�t) TEF�FiTTC��:Ir�L F;OA�iq SA�hlT F'F1ULq hlhl 5c��.�
AUthorl�ed Slgnature (Contractor or Owner Performing Installation) Please Provide Two (2) Phone Numbera Incluc
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