P - 76713., REQUEST FOR ELECTRICAL INSPECTION ���'�°�,
1�� 2��� 7 6 � Minne.sota Board of Electricity k �
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651)642-08001TY/MRS 1-800-627-3529 www.electricity.state.mn.us ;;�*�
Describe -using the back of the ite copy if necessary - the work covered by this request: �
'� i . 1 i i. t, ii , i_. O. e t�.
I SERVICES I POWER SUPPLIES
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
Each Additional Unit @
Lighting Retrofit @ $25 per Fi�ure
Center Pivot Irripation Boom (iil $4(
Traffic
Fee @ $20
up to 10 KVA @ $10
over 10 KVA C� $ 20
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Tri s @ $20
Investigative Fee
Reinsoection Fee na $20
TOTALFEE
(minimum total fee is $20)
THISAREAF SPECTORUSE
c�►c� 1 - r�� '(
I hereby certify thal I inspeded the elecUical installation describe �h rein oA'the dat�s stda�
ROUGHIN OATE
� g'- a,?
FIN4lIN5PECTION ' DATE .7
i - � �Z,v _ :
S iallnspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
I II4�' REC'D ��Pa 18 2001
���� �� ��� �� ��I � �� (�� �I ��� �� (�� �� ��) �� ��V �, ,.��/-
18202762 �W�"���b
j-� ,���. ��iz�z�_ � �-��-v�s—
Date: Rough-in Inspection Required? Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now ill Call
�'� � You must call the inspector when ready! Date Ready:
I certify that I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address City
� 'L , 4�1l� (�M Av� �irG'�G �1E• �`C �d � �M
/
any or owner i
�5�1
or O�er Perf�
ElecUical Utildy Address
Please Provide Two (2) Phone Numbers Including Area C
(�S) q�$-pC3d ( )
ise Number Master Electrician or Power Limded Tec
�� License Number /� D�/�('/
/.-W'1 ( d
-wo (2) Phone Numbe Including Area Code
=170 � � Z9t�-Srx�