P - 76273� REQUEST FOR ELECTRICAL INSPECTION
1�� J�- 5 3 8� Minnesota Board of Electricity �• �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� -¢ -- ' , (651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
. -usir�g tlie back of the white copy'rf necessary - the work covered by this request:
� EXCEI. EhIEftG� 5r1�1E�i `5 SI�ITi�H
SUPPLIES
)MMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units a�. $50 Per Unit
Vehicle Park Sftes
Traffic Signal Standard
Suoolementat Fee (�a $
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Insaection Trips a(2 $20
TOTAL FEE ��v �L
total fee is $201
that I inspected the electrical inshalla6on described herein on the dates s�ted:
� / Fl�C7 �
TH�$ IAISTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED 1MTHI(d 12 MONTHS
. REC'D J UN 14 2001
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�e� Rough-in Inspection Required? ❑ Yes � No Inspecdon Other Than Rough-In: [�Ready Now ❑ Will Call
E9! �. �. ��� You must call the inspector when readyl Date Ready:
I certify that I am the C�7 LICENSED CONTRACTOR ❑ COMPP�NY ❑ OWNER and hereby request inspection of the electrical work at
.kb Site Sheet Address City � � � � � � � q � �
41 65 1/� �I�� hfE �
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Tarmship Section Range Fire No. Cou s
Owner/Occupant Name Please Provide Two (2) Phone um rs Including Area Code
VAh1EE q �:UTH G ( � ( �
ElecMcal U61ity Electrical Udlity Address
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Contrector / Company Name Contractor License Number Master Electrician or Poxrer Limited Technician
License Number
HUh! i ELEGTF;IC CC1�;F'ORATTGh! Cr� �088�
MAiAng Addravs (Contractor, Company or Owner Perfortning Installa6on)
�3t?fi TEfiFiIiO�;It�L fi0AU9 SAIiaT F'P�tJL9 �IN 5°�1:1�
Authorized Sigr�eture (Contractor or Owmer Performing Installatlon) Please Provide Tvro (2) Phone Numbers Including Area Code
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