P - 78355" -� REQUEST FOR ELECTRICAL INSPECTION
�.!_ - 4 9�- 5 4 5� Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Sairrt Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.e[ectricity.state.mn.us
❑ NEI�V ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
� CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Retrofit � $.25 per Fixlure
'ivol Irtia�on 800m � E4L
Hour
Traffic Si nal Standard ,p_ 85
Su lemental Fee � $20
Transformers u l010 KVA $10
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns I Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amper�, All
GrouiLs and Two Inspection Trips Each Dwelling Unit @$80
TOTAL FEE I � Q� S V
(minimum total fee is�20)
T195MEAFpt CTORUSEOIIY
I hereby certify Ihal I inspecled the ebctric� install�on desaibed herein on the da�s N�ed:
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R� ete: Rough�n Inspection Required7 ❑ Yes No Inspection Other Than Rough-In: Ready Now � WGI CaA
You must call the inspector when ready! pate Ready: .
I certify at i am the ICENSED CONTRACTOR ❑C�ANY ❑ OWNER and hereby request inspection of fhe electrical wak at:
J Site Address (Street �4 a Route No.) CitY ZiP Code
�e� " �.��� -�0 � _ � l �, �Jl.n '�'��1 J �
V .
paM Name ,
��lr�
ier Power Supplie
;.ompany Name
TOTAL ELECTRIC. INC_ `
or
BACK OF
g Install ' �n) /�
BOARD OF ELECTRICITY COPV
Master Dectricien a
License Number
o�
EB-00001M74 8.1.2002