P - 76301� I�EQUEST FOR ELECTRICAL INSPECTION
1���— 5 3 0❑�1 Minnesota Board of Electricity
1821 University Avenue Sufte S-128, Saint Paul, Minnesota 55104
' . (b`51) 64a-0800 TTY/MRS 1-500-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy 'rf necessary - the work covered by this request:
E�LEL EhiEf-iL}g SA'v'ER'S SL�lITCH
GENERAL FEES Outdoor Lighting Standard @$1
S�RVIC�S I POWER SUPPLIES Traffic Siqnal Standard a(� $5
CIRCi11TS, CfRCUITS OF LESS THAN 50 VOLTS
Each�S stem Device or Apparatus @$.50
�— ADDITIONS TO THE GENERAL FEES
to 12 Units C1a $5D Per
S INSTALLATION MAY BE
-�
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�79753Q1�
Transformers over 70 KVA $ 20
Transformer I Power Supply for Signs I OuU(ne Lightlng @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$BO
TOTALFEE
total fee is $20) �= E�
I hereby certify that I inspected the electrical installaGon dascribed herein on ihe dates ataf�: �
°� � �!�C I I
TED_IF NOT COMPLETED WITHIN 12 MONTHS _____ _�
RE�D J Uld 14 2007
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I"°i°' Rough-in Inspectlon Required7 ❑Yes � No Inspection Other Than Rough-In: �Ready Now ❑Will Call
�%� �. �. f d 7 You must cail the Inspector when readyl Date Ready:
I certify that I am tha �7 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
JqbS(feStreetAddress �gy�������9 �I�
761:� �Ei�ITFiraL �aVE h!E
�+«w��w�:�+N��� �.d���r, riease rro�nde Two (2) Phone Numbere Including Area
%W�EFiq RO�:Th9 f�f�f;G.l� ( � ( �
EJOCtripl Utllity Electriql Utility Address
XI:�EL EhlEF:G i
ConVector / Company Name Contractor License Number Master Electrician or Power Limiteal l
H�JFd I ELECTfiIC GOFiFGRA I 20h� �� �j���� ���Numt�r
Mal6ng Address (Contractor, Company or Ovmer Performing Installation)
b34� iF_FiRITCiRTAL Fi17�tl�q S�`3IhlT F'f�ULq (�Ih! 55114
A oriz�l 34gnature (ConVactar or Owmer Performing Installation) Please Provide Two (2) Phone Numbers Inciuding Area
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