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P - 76097REQUEST FOR ELECTRICAL INSPECTION 1� 7� 9- 7 0 6�7 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.mn.us Describe -using e ack of the whfte copy ff necessary - the work cover�by this request: SUPPLIES ALRRM, COMMUNICATION, REMOTE CONTROL, SIGNALING CIRGUITS, CIRCUITS OF LESS THAN 50 VOLTS � Each Svstem Device or Aaaaratus (�D $.50 Standard ONE & TWO FAMILY DWELLINGS, EACH UNIT Inciudes the Service and/or Power Supply up to 500 Amperes, All Circuits and Two Inspection Trips Each Dwelling Unit @$80 MULTIFAMILY DWELLINGS PER UNI TOTAL FEE �� 3 io 12 Unns @$50 Per Unft (minimum total fee is $20) EaCh Additi0n81 UI11t @ $25 nnsr,a�aFOaws�cronuseanv OTHER ADDITIONAL FEES Lighting Retrofit @$25 per F'ucture I hereby certity that I inspected the elecVical instellaGon described herein on the dates steted: Center Pivot Irrigation Boom @$40 aou�+w on,� PAanuFactured Home Park Lots $25 Recreational Vehicle Park Sites $5 F�uwsPecnau onre � Se rate Bondin Ins ction $20 h1 �--'Z- ° Special Inspection @ $30 per Hour °w°tE01 °ATE Special Inspection @ $.31 per Mile THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS '•' � I����uII��I�uWUUII�III�AUI�IWI r� y � 1789�'067 �"�� Rough-in Inspection Required7 ❑Yes �o Inspecdon OtherThan Rough-In: ❑ Ready Nowg(Will Call ♦ ` � You must call the inspec[or when readyl Date Ready: I certiiy that I am the�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at Job Sft�Street Ad ss p ` �--- �. � � A i !M� � . _ � en /�"" � /� �. � � _ e ElecMpl UtilityA di / Company Name a � , � ress o actor, Co pany or Owner erform ng s al 'on) , i I$ Wre�ConVadarorOamerPerformj�glnsta a on) � ����� �,� ) Licenae Number Master Electrician or P Licenae Number � � �se Prowde Txro (2) Phone / /