P - 78803' REQUEST FOR ELECTRICAL INSPECTION
:1 � 4��- 0 2 9� Minnesota Board of Electricity �
1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
(651) 642-0800 T'fY/MRS 1-800-627-3529 www•electriciry.state.mn. us
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR Describe -using the bxk of the white copy if nec - the vrork covered by this request: c r�
Service U rade ��
GENERAL FEES Outdoor Li htin Standarcl $1
I
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
to 10
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andbr Power Supply up ro 500 Amperes� All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
GS PER UNI TOTAL FEE
Per unit (minimum total fee is $20)
TMS RREA FOR kLSPECT011 USE ONLY
�$25 I hereby cer0y that I inspecEed the e�ctrical inslallafion deuribe
HER ADDITIONAL FEES ,�.�ee.✓"'� r�fs� L� l� +�^r s
����
S iallns 'on $.31 Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Request Date: Roughin Inspection Requirad? ❑ Yes Inspedion Otfier Than Rough-In: �Ready Now Wil1 Cell
7- 2- 0 3 You must call the inspectar when ready! Date Ready.
I cefi(y that I am the i�LICENSEO CONTRACTOR ❑ CONPANY ❑ OWNER and hereb�r request nspection of tl�e electrica� wak at:
.ieh Site Addrasa (Street Box a Route No.l CiIY Zip Code
XCel
Contractor / Canpamy Name
Bassing Electric, In
Mailin9 Address (Contrector, Canpany or Owner Perfort
Hennenin
Please Provide Two (2) Phone Nunber(s
\ � \ /
itracta License Number Master Eleetrician or P
License Number
CA00237
pr ms�naoon� ,�,��o,�, .
763-43 -
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