P - 79116(�(� REQUEST FOR ELECTRICAL INSPECTION
1—� 11='L.J — 513 � Minnesota Board of E{ectricity -
�'?� 1821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
�.;�('/�`-'�� (651)642-0800 TTY/MRS 1-800�27-3529 www.electriciry.state.mn.us
❑ AD ITION ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
� S� C�.�"��Y',�1 c� � c' �� i' —���-�
I Above 2O0 Ampere �$10
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Exh Svstem Dev�ce w Aooaratus � 8.50
3to12
ll;l6'3
IIIII IIIII ��I�I II�I� IIIII IIIII IIIII I�III �III II�I�
17005L33
Tratfic Signal Standard
Suoolemental Fee � S
over
Includes the Service and/or Power Supply up to 500 Amperes, All
Cirouits and Two Inspection Trips Each Dwelling Unit �$BO
Additanal Ins tion Tri $20
Inves' ativeFee
Reins tion Fee $20
TOTAL fEE �(J
(minimum total fee is $20)
.res��Faemsv�cra+use r
I hereby certify that I' d the elec6'ical installa6on described I�erein on the da�es sf�ed:
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•"+""` "i1e� Rough-in Inspedion ReQuired4 Yes Hb MsPeodon Other Than Rough-In: �Ready Pbw WNI Cell
�/— `�— Yw must c�l the inspec[or when ragdyl pate ReadY
I certify ihat I am the �QCENSED CONTRACTOR ❑ COAiIPANY ❑ OWNER and hereby ►equest inspection of the electrica� wak at: