P - 781801-5��-437 �
JICES I POWER
0 to 400 Amcere
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electriaty
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-08001"TY/MRS 1-800-627-3529 www.electri�itystate.mn.ur
il
REPAIR Des�i=-using the bxk of the whfte copy'rf n - the cove2d by this request:
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
ADDITIONS TO THE
FAMILY DWELLINGS (PER UP
to 12 Units @$50 Per Unit
ach Additional Unit @ $25
rig�on Boom
Home Paric Lc
� ��� �� ��� �� ��� �� ��� �� ��� �� ��� �� ��� �� ��� �� � �
15864374
e / ••�
I certify that I am tt�e
Tralfic Si nal Standard $5
Su lemental Fee S20
Trarisfortners u to 10 KVA $10
Transformers over 10 KVA E 20
Transfortner I Power Su fa S' ns I OuBine Li htin ES
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit � S80
TOTALFEE
(minimum total fee is $20) �
TMS MEA FOR INSPECTOR ll$E OrLY
I hereby cerfiry that I inspected tlie electrical instaY�on described herein on the d�es sfa0ed:
k�9 - �-�'�`
. G' G'�%� �
, � �� � �
o�(,�-�"t ' ��7a� � n Q.� C•7,
, �- .� �
rwugnin inspecuon f�uiretl7 LJ Yes LJ No InspeGion Other Than Rough-In: Ready Npw � V1All Call
You must wll the inspecta when ready! Date Ready:
NSED CONTRACTOR ❑ COMPANY ❑ ONMER and hereby �equest inspection of the electrical woric at:
n+arnucnoMS oN ewcK oF reuow
w...w ur e�c� � ro�i i� cvPr