P - 76290—• � h�EQU�EST FOR ELECTRICAL INSPECTION
1� 7 9 7_ 513 � Minnesota Board of EJectricity _ _• ;
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
' , (�51) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
DESGribe -using the back of the white copy 'rf necessary - the work covered by this request:
E���EL EMEF:G'Y v�,s1E�'5 Sl�JI►r_H
Standard
Transfortner / Power Su I for Si ns / Outline Li htin $5
D$5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
e$10 Includes the Service and/or Power Supply up to 500 Amperes, All
TION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
OF LESS THAN 50 VOLTS Additional Ins ction Tri $20
ice or Apparatus @$.50 Investiqative Fee
m�@$;
OTHER
MAY BE ORDERED
III�liII�II�I�I�IIIN�IIIIIIIIIIIIII�' Ill�l
179751�
TOTALFEE
total fee is $201 �_ �``�
I hereby certify thffi I inspected the elecfical Installation da5cribed herein an the detes sfated:
ROUGHIN pp7E
FMAL MSPECTION pA7E
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Fl(PPIEU T ABANOON pp�
!CTED IF NOT COMPLETED WITHIN 12 MONTHS
RECD JUN 14 200�
,�D�� -DC�i�
�a�' Rough-in Inspection Required? ❑ Yes � No Inspection Other Than Rough-In: � Ready Now 0 Wfll Call
�� �. �. +'�� .�+ You must call the inspector when ready! Date Ready:
I certify that I am ths � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical vaork at
Job Sits Street Address
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TQwnship Section Range Fire No. County
�tLIi��TI�IA ZAhII�P�
Elemical Uti�ity
�CEL E{�ERG �
Please Provide Two (2) Phone Numbers I
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--�-••-�•-• -���••w��� �����p i.onuncwr ucense rvumner nnas�er r�ecmc�an or rower umrced �
FIiJ'�IT ELECTFtTC �:ORF'ORi1TZClFI f_`.A (1{}8•'.�,3 u�nseNumtrer
Mailing Address (Contractor, Company or Owner Performing Installation)
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At�,Fdo�d 6lgmature (Contractor or Ovmer Performing Installation) Please Provide Two (2) Phone Numbers Including Area
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fNSTRUC110NS ON BACK OF VELLOW COPV RnARn tiF FI FrTRIrIN rnDV �n nnn,., n,�