P - 76286Q � I�EQI�EST FOR ELECTRICAL INSPECTION
��� J!- 514 � Minnesota Board of Electricity
,L. _. _ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
' � (651) 64i-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
De�ibe -using the back of the white copy'rf necessary - the work covered by this request:
ExcE� �ra���v snvE�:•s s���rcy
_ GENERAL FEES Outdoor Liqhtlna Standard na $1
Transformers up tc
Transformers over
�u �e m�5 ONE 8� TWO FAMILY DWELLINGS, EACH UNIT
2�0 Am re$10 Includes the Service andlor Power Supply up to 500 Amperes, All
)MMUNICATION, REMOTE CANIROL, SIGNALING Circuits and Two InspecGon Trips Each Dwelling Unit @$80
CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ction Tri s $20
iystem Device or Apparatus @$.50 Investiaative Fee
Retrofit
f'tK UNI I TOTAL FEE
Unit (minimum total fee is $201 �° �'�
Park Sites
I hereby certify that I inspected the electrical inslallation d�cribed herein on the dates sla0ed: �
, ��' '�Z.(.c
THiS UNSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
II�IIIIII�I��I��III�I���IIII�IIlIIIIIII ��D �UN 14 200�
- 1"� 9 7 5 1 4 5 O�� �e �- Cr�--' %�% /
��' Rough-in Inspecdon RequiredT ❑Yes � No Inspection Other Than Rough-In: �Ready Now �Will Call
�%�. �. %�Q % You must call the inspector when ready! Date Ready:
I csfi#y that I am the 17 LICENSED CONIRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Jdb Site Street Address C�y
i49� (�lE �S�C�]hl 7�: Ffi2�LEt I'11� ci..rllJi
aawmsmp section Range FireNo. County
Owner/Occupant Name Please Provide Two (2) Phone umbers Including Area
AI%I0�' NAf,iJLD �� ( � ( �
Electricel Utility ElecMcal Utlltty Address
�CEL EhIEf;G �
Cont�ador / Company Name Contractar License Number Master ElectriGan or Power Limited T
License Number
{-IU��IT ELECTFiIC COFiF'ORATIOFd CA 4��8�
AAailing A�fdress (Contractor, Company or Owner Performing Installation)
�,�OG iEFef,TTOF�IFiL �;OAD9 Sf�ihlT F'yUL9 f�F�! 5511�
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