P - 77690REQUEST FOR ELECTRICAL INSPECTION
1— 6 41-10 9� Minnesota Board of Electricity ���� Q�� ?�
1821 University Avenue Suite S-128, Saurt a�, Minnesota 55104
(651) 642-0800 TIYlMRS 1-800�27-3529 www.electricity.state.mn.us
❑ NEW ❑ REMODEL ❑ ADDITION REPAIR Desaibe -using the back of the white copy 'rf necessay - the work covered by this request:
<-�.�..,�� n�vr�in,A� G'c,,,1, nn ��-�, _�„
0 to 400 Am ere b25 6t %`
401 to 800 Am E50
Above B00 Am re E75
CIRCUITS / FEEDERS
0 to 200 Am e ES
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CANTROL, SIGNALING
GRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Exh Svstem Device or Ao�aratus � 5.50
Each Addition� Unit
Transfortners uP to 10 KVA
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe 5ervice andlw Power Supply up to 500 Amperes, All
GrcuiLs and Two Inspection Trips Exh Dwelling Unit �$BO
Inves' ative Fee �
Reins tion Fce E20
TOTALFEE
(minimum total fee is $20)
iM5 ARE� FOR BiSPECTqi USE Q1Y
I hereby cer5ty tlwl I inspec0ed the elecbical instaNa6on described herein on Ihe aates sla0ed:
`! ..�.-=
ial Ins 'on 5.31 r Mile
ISTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WiTHIN 12 MONTHS
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16411092
Requesl Da[e: Roughin I�spection Required? ❑ Yes �b Inspection Other Then RougMn: �eady Now O WGI Call
'?�.`.� , Yau must tall ihe inspeda when reedy! paie Ready:
I certify that I am 1he LICENSED CONTRACTOR � COMPANY ❑ OWNER and hereby request inspec.•tion of the electric�al work at: