P - 77541tttQUES� FOR ELECTRIC,�_
,y, y��� I Minnesota Board of Electricity
�_] 1821 University Avenue Suite S-128, Saint Paul, Minne�.
�ss�� saz-osoo TrrIMRS 1-800-627-3529 www,electriciry.,,,
the back of the white copy if necessary - the work covered bv this reauecr
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
to 12 Units @ $50 Pe
ach�
Fixture
Outdoor
� � ransrormers over 10 KVq $ pp
� Transformer / Power Supply for Si ns / Outline Li htin a$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Uni @$gp
Additional Ins ion Tri s$20
Investigative Fee
total fee is
that I inspected the electrical installatio
— �1f�ihe^ herein on the dates stated
Q DAiE
�+ `Y., t,�yc�.� .
LTHIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS `G �
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1 8 2 0 4 9 82 `�'����°"�����
Date:
Rough-in Inspection Required? ❑ Yes ❑ Na ��
'�� ��( �t"' spection Other Than Rough-In: ❑ Ready Now �yyi�l Call
V r� You must call the inspector when ready! Date Ready:
� certify that I am the p LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site SVeet Address
( City
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OF YELLOW COPY
Fire No.
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License
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BOARD OF ELECTRICITV COPY
-� �-i • ����� �.umoers Indutling Area Code
�'�.3 ("7L3)1$�-�
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Master Electrician or power Limited Technici;
License Number
>(2) Phone Numbers including Area Code
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EB-0OOp1A45 8.1.2q