P - 75406REQUESTRFQRF�ECTRICAL INSPECTION
1° 8 2 0� 4, 2 7 � Minnesota Boarti'of Electricity
1821 University Avenua Sufte S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the whfte capy' necessary - the work covered byJ�� requesJ: �_ �
ris.�cti Nl�,^�'
GENERAL FEES Outdoor Lighrin Statidard Q$1
SERVICES / POWER SUPPLIES _ f�/I .-,_ ,.A Traffic Signal Standard @$5
200 Am�re $10
IMMUNICATION, REMOTE CONTROL
CIRCUITS OF LESS THAN 50 VOLTS
Per
Fbd�lre
,� � eT10N MAY BE ORDEKED
�
I �I�II�11�iIiQl�lllllOI�N11i��1�
IIII
18204271
ONE & TWO FAMILY OWEWNGS, tAGrt uivi i
Includes the Service andlor Pawer Supply up to 500 Amper�. All
C'vcuits arM Txro Insp�tion Trips Each Dwelling Unft @$BO
(minimum total fee is
(���� �Y��
I hereby cer�Y fhat I h�3ad tlre e�ectr�oa
� �
� , : y�`� c7cJ' O'v� ' �
°CTED IF NOT CO PM LETED WITHIN ONT S
�oNO�riceusEOw�v` �a � �..
.� ��
�� �� �� �� �
�: �, Rough-in Irrepection Required9 es ❑ No Inspectlon Other Then Rough-In: � Ready Now � WN Cali I
� ����-' � You must call the irrepedor ufien readyt Date Ready.
' I ce�tify tMat I am the � LICENSED CONTRACTOR ❑ COMPANY�WNER and hereby request inspection of the electrical work at
Job Site Street Addr�s /) � / � � �'` r 1 "' � � � � � �� � �� � �
�� -� v �v � � Y
Toamship Sectlon Range Fire No. County ���_ �
, p�mer/Occupan� Name a Please Provide Two (2) Phorre Numbers Indud'mg Area Caie
� � � i � �-5� ��+' (�7� � °J l-Y �;� � r�) �-� P � P ��;���
Amrador / Company Name
lailing Address (Contrador, Company or Ownr�r Pi
� 5; i �}- {-��S /,��'
wtne►kea sig�rea,re (co� mre�c�or or o,xrter Pertm
� S � � � �—�-� s� A- �'
��are� �rnnNC nn� Ref:K (/F YELLOYY COPY
Master Elechidan ur
Llcense Number
C ���.V � � �� r�
Please Provide Two (2) Phorre
(lb`�) �`71> tb�
,\4.�/,��ya�-1 yS ,
�y
Indudtr�g Area Code
��(zs=v��a �I
E&00001A-05 8.7.21i��