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P - 78047. � REQUEST FOR ELECTRICAL INSPECTjON 1� 5 2 9�� J � Minnesota Board of Electricity 1821 University Avenue Suite S-128, SaiM Pa�, Minnesota 55104 (651) 642-0800 TlY/MRS 1-800-627-3529 www.electricity.state.mn. us EW ❑ REMODEL ❑ ADDITI�N ❑ REPAIR Oescribe -using the back of the white copy if necessary - the work covered by this request: S"c.a vt �r crJ i�i� -- D�7's r�e I��tc.�% Ya�� ALARM, COMMUNICATION, REMOTE CONTROt CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Each Svstem Device or Aooaratus C� 5.50 3 to 12 Units Each Additio Lighting Retrofit Center Pivot Irti� Su lemental Fee $20 Transformers u to 10 KVA $10 Transformers over 10 KVA $ 20 Transformer / Power Su I for Si ns / OuUine Li htin $5 ONE & TWO FAMILY DWELLINGS, EACH UNIT Includes the Service and/or Power Supply up to 500 Amperes, All CircuiGs and Two Inspection Trips Each Dwelling Unit �$BO Addilional Ins fion Tri $20 Inves6 ative Fee Reins tion Fee $20 TOTAL FEE (minimum total fee is $20) �O r Sv iH15 MEA FOR INSPECiOR USE CMr I hereby cerfiy thal I inspected the electrical inStaY�on described herctin on the dates stated: Z -- �k i I \Y BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS (��h�� . 15293798 � �+ ��o�- ��77� o� � Hequest uate: Rough-in Inspection Required? ❑ Yes �NO Inspection Other Than Rough-In: ❑Ready Will Call —?— � 3 You must call the inspector when ready! Date Ready: I certiry that I am tt�e LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:: Jab Site Address (Street, eox, w Route No.) � Zip Code �.�0 ��v ST /�% �. �% r�[e �/ �� l BACK OF YELLOW COPY ---l�10 �,(!{ P ease Provide Two (2) Phone Number(s) Induding Area Code �78'y S.Z� ( ) tor License Number Master Electrician or Power Limited Technician License Number � Phone (s) � � � COPY EB-00001A-14 8.1.2002