P - 76283REQUEST FOR ELECTRICAL INSPECTION
���'� ca 5 2 O � ' Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
, , (651) 642-0800 Ti'Y/MRS 1-500-627-3529 www.electricity.state.mn.z�s
A�tbe -using the back of the white copy if necessary - the work covered by this request:
E�CEL EI�lE�:G� SAVEF. ° S SW i TCH
GENERAL FEES Outdoor Liahtinq Standard an $1
)MMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
iYStem Device or Apparatus na. $.50
@
Fixture
FEES
Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
TTransformer / Power Supply for Signs I OuUine Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelflng Unft @$80
Fee
� v �n� r�c y'�o `r'Y�}
total fee is $20)
that I inspecled the electrical instellation descdbed herein on the dat� sta0ed:
�re
G-'�/ e7
Sp�clal Ir� tion @$.31 per Mile
TFN$ INSTAL,LATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED 1MTHIN 12 MONTHS
REC� J UN 14 2001
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V°`O' Rough-in Inspection Required? ❑Yes .❑ No Inspection Other Than Rough-In: ��Ready Now OWill Call
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�� �. �,� 3 You must call the inspector when ready! Date Ready:
I ceftify that I am the r] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site SVeet Address C�y
�.6�(} hIE G�tRt7EN�, �11E F�eT�}LEf h1{� 55�,:8�
vwnenuccupan[ rvame Please Provide Two (2) Phone Numbers
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ElecMcal Utiliry Electrical Utility Address
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Contrectar / Company Name Contractor License Number Master Electricien or P
License Number
�-tLoha i ELEC P�IC CC��F��]�:AT'TOhI rr� �c,+gs�:;
pASlling Address (Contractor, Company or Owner Performing Installation)
�3�E1 TERf;TTOF;1.l�L FiOt�Dq SATIdT F'AIJL9 f�lh! 551ia
Authptized Sklnadue (ConVactor or Owner Parformina Installationl vtaa�A Prnv'�da Twn !91 Phnnn n�� �...�,e.a i
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