P - 76213REQUEST FOR ELECTRICAL IIVSPECTION
20 `� ��-e;� �, 9� Minnesota Board of ElecUicity - I
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Descrit� -using the back of the white copy'rf nec�ssary - the work cavered by this request: _
1MMUNICATION, REMOTE CONTROL, SIGfdALING
CIRCUITS OF LESS THAN 50 VOLTS
iystem Devfce or Apparetus @ $.50
ADDITIONS TO THE GENERAL FEES
ILY DWELLINGS (PER UNI�
! UniLs fD $50 Per Unft
Center Pivot Irtigation 800m @
Manufactured Home Park Lots
ALLATION MAY BE ORDERED
I��I II II� �I III I� �II II I�I �I I�I I) III � I�) � W I�
21678495
��ra
Su lemerdal Fee @ $20
Transformets u to 10 KVA $10
Transformers wer 10 KVA $ 20
Transformer I Pwver Su I for Si ns / OuUine Li ' $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Indudes the Service andlor Power Suppty up to 500 Amperes, M
Circuits and Two Insp�6on Trips Each Dwelling Unit @$80
AddiGonal Ir�s 'on Tri $20
InvesBgative Fee
Reins on Fes $20
TOTALFEE �q 5
(minimum total fee is $20) �CJ �
nus a�a wa msrEC'roa u� aar
I hereby certiy tlmt I inspected the electrical i�Iletlon desaibed t�erein on the dates stated:
0
CTED IF NOT COAAPLETED WITHIN 12 MONTHS
�M - � V � ��I�'CC��
o�OC�'l -Dll ��
�: I � I Rough-in InspecGon Required7 ❑Yes �No I Inspedion Other Than Rough-In: ❑ Ready Naw�WN Call
I.n '� L/� You muat call the inspector when readyl Date Ready.
\{� �
I certify that I am the �CICEJVSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request ins�tion of the elechical work at
Job Slte Street Addr�s�^ / /�) /� C�, �� A
�g � F �4 S�!'�+�'�" � v�-' �.�/�
Ple�e Provide Tvro (2) Phone Numbers
�/7' /�� /
�Nuy�r�e , Master Electriclan or P
� �7 ` � Licerree Number
l
Please Provtde Two (2) Phorre Numbers
`�)�7`� Z� )