P - 75759REQUEST FOR ELECTRICQL INSPECTION
� 1��81 � 3 2 L � Minnesota Board of Electricity a�(>Q.Sr�Q/�'D% �'s i
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
c (651) 642-0800 TTY/MRS 1-800-627-3529 www.electvicity.state.mn.us
Descrihe -using the back of the white copy if nece.ssary - the work covered by this request:
EXGEL EhIEF.GY SAVER'S SIdIiCH
I POWER SUPPLIES
Fee
10 Am re $5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
200 Ampere $10 Indudes the Service and/or Power Supply up to 500 Amperes, All
)MMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Taro Inspection Trips Each Dwelling Unit @$80
CIRCUITS OF LESS THAN 50 VOLTS Additlonal Insaecfion Trias a�. $20
ADDITIONS TO THE
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total fee is $20) 2�� °"
I herebvi certifv that I inspected the electrical installetion describai herein on ihe dates stefed:
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►Y BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12
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17813221
���`��o Ey Rough-in Inspec[ion Required7 ❑Yes �] No InspecGon Other Than Rough-In: �Ready Now ❑Will Call
You must call the inspector when ready! Date Ready.
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
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Fire No.
Ormer(�GSUp�L�O Please Provide Txro (2) Phone Numbers Inctuding Area
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ElectriGel Utility Electrical Utility Address
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Mailing Address (Contractor, Company or Owner Performing Installatlon)
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Authorl�! SI ture (Cantractor or Owner Performing InslallaUon) PI a Pro e Two� Ph ne Numbers Including Area
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