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P - 760641 7 8 7 0 4 7�g REQUEST FOR ELECTRICAL INSPECTION � � Minnesota Board of Electricity 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us '-using the back of the white copy'rf ne���ne ����,y�i��r. � Sl� I T�H GENERAL FEES Outdoor Liuhtina Standard C�a $1 CIRCURS, CIRCllITS OF LESS THAN 50 VOLTS Each System Device or Apparatus @$.50 ADDITIONS TO THE GENERAL FEES Unft i Inspectlon $30 er Hour �cial Inspection @ $.31 per Mile � fNSTALLATION MAY BE ORDERED DISCONN I(011 II I� il ill II I II II I� II I II I I I II I I� I I IN I Illi 17870478 � Trensformers up to 10 KVA @$10 � Transformers over 10 KVA @$ 20 Transfortner / Power Supply for Signs / Outline Lightin $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT Includes the Service andlor Pawer Supply up to 500 Amperes, All Circuits and Two Inspecqon Trips Each Dwelling Untt @$80 TOTAL FEE �Q, total fee is $201 electrical installe6on described hereln on the dates stated: � VYITHIPI 12 �.a��`�����- I"���� J�� Rough-in Inspectlon Required? ❑ Ye� �] No Inspection Other Than Rough-In: [�Ready Now ❑ Will Call You must call the inspector when ready! Date Ready: l r,ertjfy that I am the C*J LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at JahStleStreelAddress CitYF�aII)LEY �IiI �'''i..~'I�Js 1J5t9 i�E 751'H �VE � UhlT ELECTF.�c co�F�o��rz�r� � Address Contrectar Company ar Owner Performir J4(? T fiRTTI��aIF1L FeOAD, Srl Ovmer ge Fire No. County ��0�� Please Provide Two (2) Phone Numbers � / � / :oMractor License Number Master Electrician or P C(°y [y(?$$,j License Number q f�h! 55114 Please Provide Two (2) Phone Numbers I �65� 54b—�911 � � rairrrv rnov . ,