P - 77271REQI,!!��T�OR ELECTRICAL INSPECTION
1�1 �`t - 7 2 5� g2� Unrv rs� Ae n e 8u'd�e S- 28, Sair�t Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electriciry.state.mn.us
❑ NEW ❑ REMODE ADDI ON O REPAIR Describe -usi g the of ihe white copy 'rf necessary - the wak covered by this request:
��
GENE FEES Outdoor Li htin Standard $1
SERVICES I POWER SUPPLIES Trafic Sianal Standard F� SS
ALARM, COMMUNICATION, REMOTE CONTROL, SIGI
GRCUITS, GRCUITS OF LESS THAN 50 VOLTS
Each S stem Device w aratus E•50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNI
3 to 12 Unik � E50 Per Unit
Rehofit � E25 oer Fixtu2
Ilil II III II I�� (i III � �II II III II III II III N IN I�I
17347253
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Ci�uits and Two Inspection Trips Each Dwelling Unit � S80
TOTALFEE �1 �
(minimum total fee is $20) (� ��
na u� wa +svECroa us� orar
I I�ereby ceAfy tl�at I inapeckd Ihe Ne�bical i�talafon daaibed herein on the da�s sh�ed:
Zoz��--c�r.sz95 �
Rq1GH MI d1TE
FWLNSPECTION OATE
3-�7- �
EIIPINED/ABMD0IED DFTE
ISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
Request Date: Roughin I�spection Required? ❑ Yes ❑ No k�spedion Other Than RougMrr. O�eady Now ❑ WNI Call
1• l�_� You must call the inspada when ready! Date Ready: ( l
I certi(y that i am ihe �LICENSED CONTRACTOR ❑ COA�ANY ❑ OWNER and hereby request inspection of ihe electrical work at:
Job Site nddress (Streey eox. a RBute No.) /e7 , �'h' � _._. /1 / ZP code /��
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( �? l - l ?�3( )
nse N�bet Mestor Electrician a P
l �i / �� Lioense Number /� ..
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E&0OOO1M4 8.1.2002