P - 76287• I�EQU,EST FOR ELECTRICAL INSPECTION
1 �'7 (� � � [ � � � Minnesota Board of Electricity
1 7 J 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
«�. - _ ' , (651) 642-0800 TlY/MRS 1-800-627-3529 www.e[ectricity.state.rr�n.us
Describe -using the back of the arhite copy if necessary - the work covered by this request:
EXCEL EhfEF;G i' ��l1EFi `S S4JTi"CH
GENERAL FEES Outdoor Lighting Standard @$1
SERVICES I ROWER SUPPLIES Traffic Siqnal Standard (�a. $5
� CIRCUCTS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
�— ADDITIONS TO THE GENERAL I
Boom �
'ark Lots
ecial Ins section @$.31 er Mile
TFHS INSTALLATION MAY BE OP
I
)1��111���iII�I��I�dI�I��E! I�II
179752a.
� Transformer / Power Supply for Signs / Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Poarer Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additionai Insoecbon Trios la� $20
TOTALFEE
total fee is $201 ��a ��
I inspeded the electrical instellation described hereln on the dates s�ted: �
C- '- Z g ` °%
�ERED DISCONNECTED_IF NOT COMPLETED WITHIN 12 MONTHS ________�
REC'D JUN 14 200�
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I�"°' Rough-in Inspection Required? ❑Yes � No Inspection Other Than Rough-In: �Ready Now �WIII Call
�i j� j, �, /r�! You must call the inspector when readyl Date Ready:
I certify that I am the [� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
JOb3[teStreetAddress ��F�TI?LEY f�P� 5��;.��
55�8 h�E ?TH ST
TownshiP Section Ranpe Fire No. Counri
Owner/OGCUpent Name Please Provide Two (2) Phone Numbers
��a�S�N LTSA E�I ( � ( �
Efectrical Utility Electrical Utility Address
�GEL EhlE{"ir{
Contractor / Company Name Contractor License Number Master Electrician or P
HUh! I ELECTF;If° !:CtfsF'OfsATTQh! CA �?t?�`�',:� L�censeNumber
IQlailing Address (Contrac[or, Company or Owner PeAormfng Installadon)
�3�J4 IEf�F'Ii'�RIAL ROA�q �AIhlT F'RULq �ihl y511d
A r�ed SiBneture (Contractor or Owner Pertorming Instellation) Please Provide Two (2) Phone Numbers I
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INSTRUCTIONS ON ACK OF YELLOW COPV BOARD OF ELECTRICITV COPV
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