P - 79743REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity
� 1-396-565 �%i 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-OS00 TTY/MRS i-800-627-3529
www. electricity. sta te. mn. us
Identify the work covered by this request:
� IVEW ❑ REMODEL ❑ ADDITION ❑ REPA{R �L EMEROY SAVER'S SWITCH
0 to 400 Ampere � $1
401 to 800 Ampere �
IAIARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
to 12 Units � $50 Per
, ,�� .....,A.
�.I�.
Transtormers over 10 KVA C� $20
Transfortners / Power Supply for Signs ! Outline Lighting �$!
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
Additional Inspection Trips � $20
Fee �
FOfl INSPECTOF USE ONLY
TOTAL FEE
total fee is $201
1 hereby ceNty Mat I inspected Me eledrical installetion tlescribetl herein on ihe tlates stetetl:
FWGH IN �ATE
FINqL INSPECTION //�'� DATE �j
/ G• - �—� �`,i
FOR OFFICE USE ONLY
1 III{II IINI N�I �IN NIN IINI ii�i N� INI I�l
* 1 3965652* ��� �,�c�
Requesf �'2 Rough-in Inspection Required? ❑ Yes �No Inspection Other Than Rough-in: �Ready Now ❑ Will Call
You mus[ call the i�speaor when readyl Date Ready:
I certity that I am the � LICENSED CONtRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at: �
Job Address (Stwoi, Bo��.44auta�l � City �'� Zip Code �
/U VIt7WAT
Section Township � O O Range Fire No. County
�°��EMAN WALTER T Phone
Power Su li r�� Address
Electrical �,qpt�jp�,/,Q�1��� Contractor Licgp,Se nly�nq@� Master License Number
1"I111�11 CI.0 4�1T1 WCii
wtailing ����n�.oy,Cy�cae� P r� r�' g 7� tio�N 55114
x�Au
Authorize ' nature (�tract om an or Owner Perfortning Instellatlon) Phone �1 �29i1
�
EB-00001A-13 7/1/2000 BOARD OF ELECTRICITY COPY INSTRUCTIONS ON BACK OF YELLOW COPY