P - 75451REQUEST FOR ELECTRICAL INSPECTION r�
1��� o� 4 4 5� Minnesota Board of Electricity ( - .
1821 University Avenue Suke S-128, Saint Paul, Minnesota 55104
(651)642-0800TTY/MRS 1-800-627-3529 www.electricity.stoJe.mn.
D�cri� -usi th back of the white copy'rf ne�sary - the work cover� by this request:
N�w�3� �.:t ��euc?� 1� 2 ��llP�MS �
I CIRCUITS / FEEDERS
IMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
3 W 72 Unfts @$50 Per
Each Addfional Unit @ 9
15.��
Indude.a the Service andlor Power Supply up to 500 Amperes, AO
Circuits and Turo Ins�ction Trips Each Dwellmg Unft @$80
TOTALFEE
total fee is $20)
� . -
I hereby certHy that I U�speGed the electricel iristalllatlon desrn'bed h�efk o-^� i�
sta
�a,w � �v---- �� 2 - d �
�ectlon @ $30 r Hour �K� ��q'`"�� �O , �j ( �O
�ectlon $.31 per Mile
,� � eTION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 S
FOR OFFICE USE ONLY
I IIII lilll II�I IIII� IIIII IIIII IIIII ��I �� Il�f ����.� �
18204453 ��
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�� Rough-in Inap�tion Requfred7 �Yes ❑Ido Inspe�tion Ofher Roug In: ❑ Ready Now ❑Wm CaII
�6 31 You must call the inapector when readyl Date Ready: '� a` Q
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPAWY WNER ami hereby request inspection of the el�trical work at
Job Site Street Addresa City
�(540 h`.�� il�/�( N� �D��(
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ntrador / Comoanv Name
W �UF-�"�
oanv or Ormer F
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'rovide Taro (2) Phorte Number
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iber Meater ElecVidan or
Llcenae Number
g Area Code
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�cludirtg Area
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