P - 78097Cc REQUEST FOR ELECTRICAL INSPECTION
1� J V�� — 0 2 6� Minnesota Board of Electriciiy -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
C�Yj31� (651)642-0800TTY/MRS1-800-627-3529 www.electricity.state.mn.us
D NEW MODEL O ADDITION ❑ REPAIR Describe -using the back oi e white copy if necessary - the work covered by this request:
` �c�o ��� C1o5 � —1 - �1885
GENERAL fEES Outdoor ' htin Standard $1
SERVICES / POWER SUPPLIES Traffic S' n� Standard $5
0 to 400 Am e$25 Su mental Fee $20
401 to 800 Am e E50 Transformers u to 10 KVA $10
Above 800 Amcere � E75 T.���R ��a, � n uvn n c�n
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Anoazatus � 5.50
$50 Per Unit
Unit � $25
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�k Lots S
'�Ic Sites '
�ection b2�
�30 cer Fbur
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two InspecGon Trips Each Dwelling Unit @$80
TOTALFEE
(minimum total fee is $20) ,,�' 6, S�
TFtlS MEA Fdt MbPECiOR USE p1V
I hereby cer0y tlwt I inspec0ed the ekttrital insfallatipn described herein on the dates sfafed:
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15670268 ���
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I certify ihat I am the
Jab Site Address (Stre
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Rough�n Inspection Required? ❑ Yes No Irupection Other Than Rough-tn: ❑Ready Now II Call
Vou must call the inspector when ready! Date Ready:
�ENSED CONTRACTOR ❑COMPANY ❑ OWNER and hereby request inspection of tlie electrical work at:
or Route No.) CitN ZiP Code
I �rs�e i ; L' ; N� _ �r; d 1 �.�-z �S � 3 �
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rer Supplier Power Suppl i ress
Ce�ttecPofnt Ensrgy : Mr�oo
,aaaor � compa�,y H Ye c«,aactw Li�
HQm Lake, NIN 55.344 4' Q
ling Add�s (CoMractw� �rming InsteAation)
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UCTIOMS � BACK OF ELECTRICT' COPY
�f�ro,�.
Please Provide Two (2) Phane Pkimber(s,
hr�)�s�ta•aa�s( )
master eiectndan a
License Number
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EB-00001A-14 8.1.2002