P - 77556(� REQUEST FOR ELECTRICAL INSPECTION
1� 4 2 4�� J� a Minnesota Board of Electricity ���-0/0�] �
1821 University Avenue Suite S-128, Saurt aul, innesota 5�10
` �(651)642-080011Y/MRS 1-800-627-3529 www.electricity.state.mn.us
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I❑ NEW ❑ REMODEL ❑ ADDITION ,�O gEPAIR � Describe -us�g the�ack oi�he white copy if necessary - the work covered by this request:
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)MMUNICAI ION, REMOTE CONTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Apparatus Q$.50
ADDITIONS TO THE GENER4L FEES
3to12
Each A
Center
Transformers over 10 KVA $ 20
Transiortner I Power Su fw S' ns I OuUine Li h6n $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Inciudes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
Additional Ins tion Tri a20
Inves6 ative Fee
Reins tion Fee 320
TOTALFEE
(minimum total fee is $20)
TIXS�REAFORI p;
1 hereby cer6ly that I inspecOed the ek�cbic� installa6on described herein on the dafes stated:
9ondin ins tion S20 —`— �- Z"rJ - G'j'
S I� IIIS �Ofl $� f �iOUf E�'�°�'��ED untE
S 'al Ins 'on $.31 r Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 M NTHS
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�� • Rough-in I Required? � Yes No Ins
pection Other Than RougMn: y Now � Will Call
You must call the inspecla when ready! Date Ready:
I cefi(y that I am CENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of tlie electrical work at:
Job Site Address (Street, � Royt� No.� Z C�i C� � / Zip Code
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NI87RUC' �OIIS ON BACK OF YELLOW COPY BOARD OF ELECTRICT' COPV
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Master ElecVician or Power Limited Technician
License Number
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E tA-14 8.1.2002