P - 77052REQUEST FOR ELECTRI L INS ECTION -
1 � Q ) � � J � 4 -�; Minnesota Board of Electricity ���� � (o�� �-
�� L � 1821 University Avenue Suite 5-128, aint Paul, Minnesota 551 4 �
(651) 642-0800 TTY/M RS 1-800-627-3529 www. electricity. state. mn. us
Describe -using the back of the white copy'rf necessary - the work covered by this request:
I SERVICES I POWER
ALARM, COMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or aratus a$.50
ADDITIONS TO THE GENERAL FEES
Each Additional Unit
Center Pivot Irrigation Boom @
Manufactured Home Park Lots p
Recreational Vehicle Park Sites
Outdoor Li htin Standard $1
Traffic Si nal Standard �$5
Su lemental Fee a $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns I Outiine Li htin $5
ONE 8 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
i�ih�rcc �y.� /�
total fee is $20) p�V •�V
I hereby ceAiTy that I inspec[ed the electrical installatlon described herein on ihe dates staled: �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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1 9 2 6 9 3 4 9
Date: Rough-in Inspection Required? �Yes No Inspection OtherThan Rough-In: ❑ Ready Now ill Call
You must call the inspector when ready! Date Ready:
I certi(y that I am the�ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address � - C� '
f� P. P,
:�I':` Elecfiric Services
, o o r Pe tion;
. . . ■
�
Fr.mir.m
� / � �
Number Master Electrician or Power Limited Technician
� License Number