P - 76276• E�EQUEST FOR ELECTRICAL INSPECTION
1����-� 3 4� Minnesota Board of Electricity
-"' 1821 U�iversity Avenue Suite S-128, Saint Paul, Minnesota 55104
' , (651) 64�-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Dgscribe -using the back of the whfte copy'rf necessary - the work covered by this request:
E�CEL Ct(E�'G`r 5�91�EF� `S a�lIT� {-1
GENERAL FEES Outdoor Li hting Standard @$1
SERVICES ) POWER SUPPLIES Traffic Sianal Standard na $5
�11TS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
�IFANHLY DWELLINGS (PER UNI'�
3 to 12 Units @$50 Per Unit
Lots
S�ecial Inspection @$.31 per Mile �
1$ t1�STAtLATION MAY BE ORDERED DISC
I I�II II �I II N111 ID a 1110 I� II III ��I II I� I
17975343
Transformers up to 10 KVA @$10
Transformers over 10 KVA (�a. $ 20
Includes the Service and/or Power Supply up to 500 Amperes, All
Circufts and Two Inspection Trips Each Dwelling Unit @$80
Fee @ $20
TOTAL FEE �0 5r�
iimum total fee is $20)
I hereby certiry that I inspected the elecMral installalion described herein on ihe data9 steted: I
� /�
REC� JUN 14 2007
��o� Dioi�
���' Rough-in Inspection Required7 ❑Yes �]No Inspection OfherThan Rough-In: [�Ready Now �Will Call
6%�. �. J'� � You must call the inspector when readyl Date Ready:
I certity that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OINNER and hereby request inspection of the electrical work at
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O�ner/Occupant Name Please Provide Two (2) Phone Numbers Including
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Elecbicel Utllity Electrical Utility Address
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Contradpr / Cnmpany Neme Contractor License Number Master Electrician or Power Lim
Ht)h! I EL�L 1 fiIC CElF;F'pRf-tTIQI•I C�i t)?)$8,3 LicenseNumber
Ma�7ing Address (Contractor, Company or Owner Performing Instella6on)
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A4Utorked $ignature (Contractor or Owner Pedortning Installatlon) Please Provide Two (2) Phone Numbers Including
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