P - 783901-4�3-372�
❑ NEW ❑ REMODEL ADDITION ❑
lJ.�.}-��0.
GENERALFEES
SERVICES I POWER SUPPLIES
2M, COMMUNICATION, REMOTE CONTROL,
;UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Appazatus @$.50
ADDITIONS TO THE GENERAL F
iIFAMILY DWELLINGS (PER UNIT1
3 to 12 Units �$50 Per Unit
E�h AddiUonal Unil � $25
Center Pivot Irtiaation Boom
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-&27-3529 www.electriciry.state.mn.us
2 Describe -using the back of the white copy if necessary - the work covered by this request:
Outdoor
Standard
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes tl�e Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additionai Inspsction Trips $20
Inves6aaGve Fee
TOTALFEE I
(minimum total fee is $20) �„
rws naEn Fort insvEC�oa usE orar
1 hereby certi(y that I inspected Ihe electrical insfallaGon described herein on tlie d�es sla�d:
� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT GOMPLETED WI 1 MIN 7"l MUIV 1 F1� �
:
I IIII II III II ill II 01(i III II III II III II III II hl I ��h r�r
14133722 j�/�(���
1�
�l�. 50
Requ Date: Rough�n Ins` ''on Required? ❑ Yes No Inspec�ion Other Than Rough-In: dy Now O W�1 Cail
a0 Q�' You must call the inspector when ready! pate Ready: .
I certiy that I am the � ICENSED CONTRACTOR 0 COMPANY ❑ OWNER and hereby request inspection of tl�e eiectric�l work at:
Job SRe Address (St^� Box, or Route No.) Cily ZiP Code
/5'33 �E�ernP_ i�oc�.c� -�rri �. I e;c� � a/
/ �^�! �
ie
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..x�rrtrr,.r�
ig Address (Contra f
'�aa � �9
BACK OF YELLOW COPY
�le�-�-�� � I cA� ,
Nner Performi^� Installadon)
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or er Perfortning ��stauanon)
BOARD OF ELECTRICITY CAPY
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Please Provide Twa (2) Phone Number(s) Ind�ing M
(���s�-a°�3 (��)a38-
nnaster tiecmaan a
License Number
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EB-00001A•14 8.7.2002