P - 76987REQUEST FOR ELECTRICAL INSPECTION
I�� 8 2 0'� �r8 3 Minnesota Board of Electricity
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--�� �� 1821 University Avenue Sufte S-128, Saint Paul, Minnesota 55104 -
(651)642-0800TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -usirg the back of the white copy rf necessary - work covered by this request:
GENERAL fEES Outdoor L' hti Standard (a� $1
SERVICES! POWER SUPPLIES Traffic Sianal Standard � 55
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units �;50 Per Unil
Each Addidonal Unit � 325
OTHER ADDITI01
L'.qhtirW Retrofit CaR 5.25 oer Fixture
FIOUf
Transfortners u to 10 KVA $10
Transfartiers over 10 KVA @$ 20
Transfortner / Power SuDDN for Signs I Outline Liphting �$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Indudes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Twa Inspecfion Trips Each Dwelling Unit @ Z80
Additional Ins ection Tri s�$20
Investi ative Fee
R ' ' Fee $20
TOTALFEE �
(minimum total fee is $20) �D . `
I hereby certify fhat I inapedad the elec�ical fnstallatlon described herein an the dat� slafed: I
_ TL HIS INSTALLATION MAYBE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 72 MONTHS _�
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��� f�C'D M AY ��2 9 2001
IN��I���I��II�������I�II
1 8 2 0 2 8 3 8 ���/��f�,��. f� ��// _
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��' Rough-in Inspection Required? ❑ Yes ❑ No InspecUOn Other Than Rough-In: ❑ Ready Now ❑ WiN Call
��� O� You must call ttie inspedw when readyl Date Ready:
I cer6fy that I am ihe � UCENSED CONTRACTOR ❑ COMPANY OWNER and he�eby request inspedion of the electrical worlc at
Job SiEee/ f0 Addre �l�N �c�e �I � C��/C /�. � \.�A
S
��Y
, Company a Owner
itractor or Owner Perl
Address
��� 78'6 ��( )
\ �
Master Electrician or Power LlmRed
License Number
Two
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