P - 761101-787-040 3❑
Desc�ibe -usiny the back o�the white copy'rf ne�
.� °
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
=�7e�`��"h��y���i�'S SWZTCH
Outdoor Liqhtinq Standard a�. $1
)MMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
N+ISTALLATION MAY BE OR�
II� � II� �I� � Al II AI (I UI II II) � I�� (I I� I��
1787040�
Transfortners over 10 KVA $ 20
Transformer I Power Supply for Signs / OuUine Lighbng @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circu'rfs and Two Inspection Trips Each Dwelling Unft @$80
TOTALFEE
total fee is $201
I he2by certi(y that I inspected the electrical insfaVation descrlbed herein on the dates stet�: �
IF NOT COMPLETED WITHIN
�.o o — c� � � � S
�
`v6r �G
��' Rough-in Inspection Required7 ❑ Ye� �] No Inspection Other Than Rough-In: [�Ready Now ❑ Wfll Call
���.���6
You must call the inspector when ready! Date Ready:
l c�ri�q that I am the f� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address ��F Fi I DL EY hi h!
°�8�7 h!E iTH Sl" 554:i�—�56,'s
TaWnShlp Section Range Fire No. Couniy
A{aoxi�
����ntC AYf Ghl �1 P��� PfO�de Two (2) Phone Numbers Including Area Code
� � � �
E CE� EhIERGY Electrical UtllityAddress
aacwr i �umpe�Y name Contrector License Number Master Electrician or P
Ui�l7 ELECTFiIG CORF'OFeATTQh! GA 00$8,:t ��enseNumber
ttg Address (ConVactor, Company or Owner Performin Installation)
�i�� 7EF;f;I1'OEI�L Fii7ADq SA�i�T F'AUL9 �Ihl 55114
�d S nature (Contractor or Owner Performing Installation) Please Provide Two (2) Phone Numbera
�� (�5� 6�6—�911 � )
RIICTIfINC (1N RA(:K f1F VF11 !1W f:nPV aneon nr �i �rroir�TV rne..