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P - 77666REQUEST FOR ELECTRICAL INSPECTION 1��� L� � 61 �� Minnesota Board of Electriaty 1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104 (651) 642-0800 1TY/MRS 1-800-627-3529 www.electriciry.state.mn.ur ❑ NEW REMO L❑ ADDITION REPAIR Describe -using the back of th�ite copy ff necessary - the xrork covered by this request: SJ P< i rw1 dG ,p S��JI'Ce "�' i� C✓ �C�y�' C�avSo� GENERAL FEES Outdoor Li htin Standard a1 SERVICES I OWER SUPPLIES TraRc Si nal Standard $5 � 0 to 400 mpere @ 5 Suoolemental Fee (a 520 ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS 2 Units @ $50 Per Unit Additional Unit @ $25 OTHER ADDITIO ng Retrofit @ $.25 per Fixture :r Pivot Irrigation Boom � $4( factured Home Park Lots � � :ational Vehicle Park Sites (al. raie Bonding Inspection @ S2 al Inspection �D S30 cer Hour Ilil lllll lllil (llll llll! IIIII IIIII IIIII �� I� 17126111 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT Includes ihe Service andlor Power Supply up to 500 Amperes, All Circuits and Two Inspection Trips Each Dwelling Unit �$80 TOTALFEE �^ (minimum total fee is $20) � �� J � THIS AREA FOR INSPECiqi USE IXJIY I hereby cer6fy lhat I inspected the ek�cbical insGllation described herein on the dates sfated: v� �MPLETED WITHIN 12 MONTHS _ I Kequesc uace: Rough-in Inspection Required? ❑ Yes � No Inspedion Other Than Rough-In: ❑Ready Now Will Call 9' C�' �S You must call the inspecta when ready! Date Ready: g— v' � I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of tt� elecfical work at: Job Site Address (Street, BoX a Route No.) City Zip Code 7�99 Ald�� ��, � �r�'��P � s� y 3 a �ia r ,�n �1� Power Suppli �Ccel e Cantractor / Company Name C �w Pc�' Mailing Address ( or pan or Own� �(o�t � v4� Authorized Signa ( ompan or iNSntucna�s oN e�cK oF reLLOw �n� k� Please Provide Two (2) Phone Number(s) InGuding , bb�l.zya-6�ot1 ( ) Address ��►PS�nuf hj/`e �✓% lf !mn/ <3SS°� Contrada License Number aster ec6ridan or Power Limite c�d y3 s� � ��ce;� � 6� � C BOMD OF ELECTRICITV COPY n� SS3 / Phone (s) ��3 S/� �- yy � 3 EB-0OOO1M/4 8.1.2002