P - 77233REQUEST FOR ELECTRICAL INSPECTION
1� 7 3 6- 2 0 6� Minnesota Board of ElecUicity -
1821 University Avenue Suite S-128, Sairrt Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-500-627-3529 www.e%ctricity.state.mn.us
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using ihe back of the white copy if necessary - the work covered by this request:
S-Gt i cu .i .� C�' I�L--Fii e_ �6 h �n�cll -�'
SERVICES I POWER SUPPLIES
0 to 400 Amcere � E25
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Additional Unit �
�
I IIII II II! II III �� �I II III II lil II III �� I�
17362062
Traffic Si nal Standard S5
Su lemental Fee p $20
Transfortners u to 10 KVA $10
Transformers over 10 KVA � 20
Transformer I Power Su for Si ns I Outline Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the 5ervice and/or Power Supply up to 500 Amperes, Ali
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ S20
Inves6aative Fee
tota� ree is s2o� I' .�(c �
I hereby certify tl�at I inspected the electrical i�alla6on described herein on fhe dffies sUBed:
S^�, / c�'7�-
� o�s -� �� �5 �
Requ�t�e �/ Ragh�n InspeUion Required? ❑ Yes ❑ No Inspection Other Than RougMn: �ady Now ❑ WNI Call
,�/ '�/ ,7 Vou must call the inspeda when ready! Date Ready. \
I cer�M' y ath t I am tlie �LICENSED CONTRACTOR 0 COA�ANY ❑ OWNER and hereby request inspecfion of the electrical wak at: